Provider Demographics
NPI:1164777090
Name:OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-634-1146
Mailing Address - Street 1:23430 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4720
Mailing Address - Country:US
Mailing Address - Phone:310-373-0555
Mailing Address - Fax:310-373-5655
Practice Address - Street 1:3300 W COAST HWY
Practice Address - Street 2:SUITE A
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4007
Practice Address - Country:US
Practice Address - Phone:949-209-0220
Practice Address - Fax:949-270-5139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A101432081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6602160002Medicare NSC