Provider Demographics
NPI:1518161934
Name:SO BAY SURGICAL CARE GROUP
Entity Type:Organization
Organization Name:SO BAY SURGICAL CARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:G
Authorized Official - Last Name:MITTLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-540-1213
Mailing Address - Street 1:23500 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4702
Mailing Address - Country:US
Mailing Address - Phone:310-784-2710
Mailing Address - Fax:
Practice Address - Street 1:21250 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5506
Practice Address - Country:US
Practice Address - Phone:310-540-1213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2620213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty