Provider Demographics
NPI:1922171008
Name:SOUTH COAST ENDOCRINOLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH COAST ENDOCRINOLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-717-7923
Mailing Address - Street 1:1401 AVOCADO AVE
Mailing Address - Street 2:101
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7720
Mailing Address - Country:US
Mailing Address - Phone:949-717-7923
Mailing Address - Fax:
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:101
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7720
Practice Address - Country:US
Practice Address - Phone:949-717-7923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15895Medicare ID - Type Unspecified