Provider Demographics
NPI:1083822639
Name:SOUTH COUNTY URGENT CARE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH COUNTY URGENT CARE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-218-8050
Mailing Address - Street 1:1300 AVENIDA VISTA HERMOSA
Mailing Address - Street 2:#100
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6315
Mailing Address - Country:US
Mailing Address - Phone:949-218-8050
Mailing Address - Fax:949-218-8051
Practice Address - Street 1:1300 AVENIDA VISTA HERMOSA
Practice Address - Street 2:#100
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6315
Practice Address - Country:US
Practice Address - Phone:949-218-8050
Practice Address - Fax:949-218-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP30274207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05603ZOtherBLUE SHIELD
CA=========OtherTAX IDENTIFICATION NUMBER
CAW16193Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER