Provider Demographics
NPI:1568453967
Name:WEST COAST ORTHOPAEDIC MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:WEST COAST ORTHOPAEDIC MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOSCARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-821-0707
Mailing Address - Street 1:301 W HUNTINGTON DR
Mailing Address - Street 2:SUITE 408
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3462
Mailing Address - Country:US
Mailing Address - Phone:626-821-0707
Mailing Address - Fax:626-821-0239
Practice Address - Street 1:301 W HUNTINGTON DR
Practice Address - Street 2:SUITE 408
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3462
Practice Address - Country:US
Practice Address - Phone:626-821-0707
Practice Address - Fax:626-821-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568453967Medicaid
ZZZ577232OtherBLUE SHIELD
W14198AMedicare PIN
CH9428Medicare PIN
ZZZ577232OtherBLUE SHIELD