Provider Demographics
NPI:1790990257
Name:SOUTH COUNTY PHYSICIANS MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:SOUTH COUNTY PHYSICIANS MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-343-8884
Mailing Address - Street 1:PO BOX 8907
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-8907
Mailing Address - Country:US
Mailing Address - Phone:714-546-7118
Mailing Address - Fax:
Practice Address - Street 1:11180 WARNER AVE
Practice Address - Street 2:165
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7501
Practice Address - Country:US
Practice Address - Phone:714-751-0995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16624Medicare ID - Type Unspecified