Provider Demographics
NPI:1609853688
Name:SOUTH COUNTIES PEDIATRIC CRITICAL CARE MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTH COUNTIES PEDIATRIC CRITICAL CARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-966-7253
Mailing Address - Street 1:17100 EUCLID ST
Mailing Address - Street 2:ATTN: PICU
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4004
Mailing Address - Country:US
Mailing Address - Phone:714-966-7253
Mailing Address - Fax:
Practice Address - Street 1:17100 EUCLID ST
Practice Address - Street 2:ATTN: PICU
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4004
Practice Address - Country:US
Practice Address - Phone:714-966-7253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57330ZMedicaid