Provider Demographics
NPI:1043242555
Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-608-0044
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:3RD FL PHR GROUP & PROVIDER ENROLLMENT
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7914
Mailing Address - Fax:626-405-4600
Practice Address - Street 1:9400 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2246
Practice Address - Country:US
Practice Address - Phone:562-461-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ38880ZMedicaid
CAW394Medicare PIN