Provider Demographics
NPI:1487044384
Name:SANTA MONICA GI MEDICAL GROUP
Entity Type:Organization
Organization Name:SANTA MONICA GI MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-385-3200
Mailing Address - Street 1:PO BOX 54679
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0679
Mailing Address - Country:US
Mailing Address - Phone:310-967-1884
Mailing Address - Fax:310-967-1800
Practice Address - Street 1:200 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1769
Practice Address - Country:US
Practice Address - Phone:310-967-1884
Practice Address - Fax:310-967-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13103AMedicare Oscar/Certification