MEDICARE: SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1891873303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	393 E WALNUT ST
Second Line	:	3RD FL PHR GROUP & PROVIDER ENROLLMENT
City	:	PASADENA
State	:	CA
Zip	:	91188-0001
Country	:	US
Telephone Number	:	626-405-7914
Fax Number	:	626-405-4600

Provider Business Practice Location Address
First Line	:	11668 SHERMAN WAY
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91605-5831
Country	:	US
Telephone Number	:	818-503-6800
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE MEDICAL DIRECTOR
Name	:	DR. RAMIN DAVIDOFF
Credential	:	MD
Telephone Number	:	877-608-0044

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	05/27/2021

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