Provider Demographics
NPI:1013013770
Name:SOUTHERN CALIFORNIA COLON AND RECTAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA COLON AND RECTAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-609-0500
Mailing Address - Street 1:23961 CALLE MAGDALENA
Mailing Address - Street 2:#231
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-609-0500
Mailing Address - Fax:949-609-0504
Practice Address - Street 1:23961 CALLE MAGDALENA
Practice Address - Street 2:#231
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-609-0500
Practice Address - Fax:949-609-0504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79692208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G69030Medicare UPIN
CAW15973AMedicare PIN
CAW15973Medicare PIN