Provider Demographics
NPI:1982631412
Name:UROLOGY CENTER OF SO CALIF MEDICAL GROUP INC
Entity Type:Organization
Organization Name:UROLOGY CENTER OF SO CALIF MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MADHUMITHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-677-3000
Mailing Address - Street 1:801 S. MAIN STREET
Mailing Address - Street 2:#201
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3410
Mailing Address - Country:US
Mailing Address - Phone:951-735-2700
Mailing Address - Fax:951-735-7564
Practice Address - Street 1:28078 BAXTER RD
Practice Address - Street 2:#450
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1402
Practice Address - Country:US
Practice Address - Phone:951-677-3000
Practice Address - Fax:951-672-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090700Medicaid
CAZZZ02498ZOtherBLUE SHIELD
CAZZZ08232ZOtherBLUE SHIELD
CAGR0090703Medicaid
CAGR0090700Medicaid