Provider Demographics
NPI:1316027279
Name:SORAYA ANNE ROSS MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SORAYA ANNE ROSS MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SORAYA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-888-1234
Mailing Address - Street 1:8920 WILSHIRE BLVD STE 321
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2003
Mailing Address - Country:US
Mailing Address - Phone:310-888-1234
Mailing Address - Fax:310-888-1227
Practice Address - Street 1:8920 WILSHIRE BLVD STE 321
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2003
Practice Address - Country:US
Practice Address - Phone:310-888-1234
Practice Address - Fax:310-888-1227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0100X
CAG51213302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19748Medicare PIN