MEDICARE: SOUTHERN MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	A62362	CA
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	A62362	CA
3	208100000X	Physical Medicine & Rehabilitation Physician	A62362	CA
4	208D00000X	General Practice Physician	A62362	CA
5	208VP0000X	Pain Medicine Physician	A62362	CA
6	2083X0100X	Occupational Medicine Physician	A62362	CA

General Provider Information

NPI Number	:	1700274982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	4014 LONG BEACH BLVD
Second Line	:	SUITE 100
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5407
Country	:	US
Telephone Number	:	562-426-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	4014 LONG BEACH BLVD
Second Line	:	SUITE 100
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5407
Country	:	US
Telephone Number	:	562-426-4900
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAHIL RASHID KHAN
Credential	:	M.D.
Telephone Number	:	562-426-4900

Provider Enumeration Date	:	12/22/2014
Last Update Date	:	12/22/2014

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Directions to “SOUTHERN MEDICAL CORPORATION ” Practice Location

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