Provider Demographics
NPI:1518975622
Name:SOUTHERN CALIFORNIA MINIMAL INVASIVE ENDOSCOPY INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA MINIMAL INVASIVE ENDOSCOPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERGIS
Authorized Official - Middle Name:RAID
Authorized Official - Last Name:GHOBRIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-426-0147
Mailing Address - Street 1:541 GREEN ACRE DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3603
Mailing Address - Country:US
Mailing Address - Phone:562-426-0147
Mailing Address - Fax:888-206-5318
Practice Address - Street 1:2650 ELM AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1651
Practice Address - Country:US
Practice Address - Phone:562-426-0147
Practice Address - Fax:888-206-5318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA533370261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A533370Medicaid
CAG63479Medicare UPIN
CA00A533370Medicaid