Provider Demographics
NPI:1598998502
Name:SOUTH COAST DIAGNOSTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTH COAST DIAGNOSTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-500-6804
Mailing Address - Street 1:7095 HOLLYWOOD BLVD
Mailing Address - Street 2:742
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-8903
Mailing Address - Country:US
Mailing Address - Phone:310-431-5753
Mailing Address - Fax:
Practice Address - Street 1:7095 HOLLYWOOD BLVD
Practice Address - Street 2:742
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-8903
Practice Address - Country:US
Practice Address - Phone:310-431-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60418207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH38172Medicare PIN