Provider Demographics
NPI:1477317667
Name:PNC PODIATRY OF SOUTHERN CALIFORNIA PC
Entity Type:Organization
Organization Name:PNC PODIATRY OF SOUTHERN CALIFORNIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:M
Authorized Official - Last Name:REYZELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:415-292-0638
Mailing Address - Street 1:PO BOX 31502
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0168
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:310-828-2001
Practice Address - Street 1:2121 WILSHIRE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5742
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:310-828-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty