Provider Demographics
NPI:1790880458
Name:SOUTHERN CALIFORNIA HOSPITALIST NETWORK MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA HOSPITALIST NETWORK MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-202-2330
Mailing Address - Street 1:PO BOX 8206
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92812-0206
Mailing Address - Country:US
Mailing Address - Phone:714-780-5695
Mailing Address - Fax:714-780-5694
Practice Address - Street 1:2040 S SANTA CRUZ ST STE 240
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6805
Practice Address - Country:US
Practice Address - Phone:714-202-2330
Practice Address - Fax:714-333-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH69723Medicare UPIN
CAH64011Medicare UPIN
CAH92224Medicare UPIN
CAW15183Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CAF92807Medicare UPIN
CAH18656Medicare UPIN
CAH04765Medicare UPIN
CAH21417Medicare UPIN
CAH60446Medicare UPIN
CAH66325Medicare UPIN
CAE92948Medicare UPIN
CAI27332Medicare UPIN