Provider Demographics
NPI:1770643645
Name:GOLDEN STATE SPORTS INJURY AND ORTHOPEDIC MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:GOLDEN STATE SPORTS INJURY AND ORTHOPEDIC MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:PERELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-998-8400
Mailing Address - Street 1:18531 ROSCOE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4641
Mailing Address - Country:US
Mailing Address - Phone:818-998-8400
Mailing Address - Fax:818-998-8404
Practice Address - Street 1:18531 ROSCOE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4641
Practice Address - Country:US
Practice Address - Phone:818-998-8400
Practice Address - Fax:818-998-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32643207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC32643DMedicare ID - Type Unspecified
CAA35013Medicare UPIN