Provider Demographics
NPI:1891873303
Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-608-0044
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:3RD FL PHR GROUP & PROVIDER ENROLLMENT
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7914
Mailing Address - Fax:626-405-4600
Practice Address - Street 1:11668 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-5831
Practice Address - Country:US
Practice Address - Phone:818-503-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0698400Medicare PIN