Provider Demographics
NPI:1275686818
Name:GASTROENTEROLOGY ASSOCIATES OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES OF SOUTHERN CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MORDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUCHOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-5940
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:SUITE 707
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2320
Mailing Address - Country:US
Mailing Address - Phone:213-483-5940
Mailing Address - Fax:213-483-9084
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 707
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2320
Practice Address - Country:US
Practice Address - Phone:213-483-5940
Practice Address - Fax:213-483-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064560Medicaid
W3429Medicare ID - Type Unspecified