Provider Demographics
NPI:1639141153
Name:KERLAN-JOBE ORTHOPAEDIC CLINIC
Entity Type:Organization
Organization Name:KERLAN-JOBE ORTHOPAEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAMBARDELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-665-7235
Mailing Address - Street 1:6801 PARK TER
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:310-665-7235
Mailing Address - Fax:
Practice Address - Street 1:6801 PARK TER
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-665-7235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ56988ZOtherBLUE SHIELD OF CA
CAZZZ56985ZOtherBLUE SHIELD OF CA
CAZZZ98667ZOtherBLUE SHIELD OF CA
CAZZZ788127Medicaid
CAZZZ98667ZOtherBLUE SHIELD OF CA
CAW1065EMedicare ID - Type Unspecified
CAZZZ56988ZOtherBLUE SHIELD OF CA
CAZZZ788127Medicaid