Provider Demographics
NPI:1689601536
Name:UROLOGY CENTER OF SO CALIF MEDICAL GROUP INC
Entity Type:Organization
Organization Name:UROLOGY CENTER OF SO CALIF MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SY
Authorized Official - Middle Name:
Authorized Official - Last Name:TSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-735-2700
Mailing Address - Street 1:801 SOUTH MAIN ST.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882
Mailing Address - Country:US
Mailing Address - Phone:951-735-2700
Mailing Address - Fax:951-735-7564
Practice Address - Street 1:801 SOUTH MAIN ST.
Practice Address - Street 2:SUITE 201
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882
Practice Address - Country:US
Practice Address - Phone:951-735-2700
Practice Address - Fax:951-735-7564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02497ZOtherBLUE SHIELD
CAGR0090701Medicaid
CAZZZ21089ZMedicare ID - Type UnspecifiedGROUP NUMBER