Provider Demographics
NPI:1639100662
Name:SOUTHERN CALIFORNIA INFECTIOUS DISEASE MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA INFECTIOUS DISEASE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:FISHBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-274-6671
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:SUITE 820
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2320
Mailing Address - Country:US
Mailing Address - Phone:213-483-0901
Mailing Address - Fax:213-483-6650
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 820
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2320
Practice Address - Country:US
Practice Address - Phone:213-483-0901
Practice Address - Fax:213-483-6650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW11997207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11997Medicare ID - Type Unspecified