Provider Demographics
NPI:1881639946
Name:SOUTH COAST GYNECOLOGIC ONCOLOGY, INC
Entity Type:Organization
Organization Name:SOUTH COAST GYNECOLOGIC ONCOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-455-5524
Mailing Address - Street 1:5030 CAMINO DE LA SIESTA STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3118
Mailing Address - Country:US
Mailing Address - Phone:858-455-5524
Mailing Address - Fax:858-480-3910
Practice Address - Street 1:5030 CAMINO DE LA SIESTA STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3118
Practice Address - Country:US
Practice Address - Phone:858-455-5524
Practice Address - Fax:858-587-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66287174400000X
CAA65396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75830Medicare UPIN
CAI13908Medicare UPIN