Provider Demographics
NPI:1760679856
Name:SCCC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SCCC A MEDICAL CORPORATION
Other - Org Name:SOUTHERN CALIFORNIA CARDIOVASCULAR CONSULTANTS
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AYLIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:HEMELIANS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MHA
Authorized Official - Phone:818-242-8816
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-242-8816
Mailing Address - Fax:818-242-0610
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-242-8816
Practice Address - Fax:818-242-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0057810Medicaid
CA1407972821OtherNPI GOODWIN
CA1366585309OtherNPI WEN
CA1851434898OtherNPI O'CONNOR
CAGR0057810Medicaid