Provider Demographics
NPI:1992838429
Name:SOUTHLAND RENAL MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SOUTHLAND RENAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CORA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-630-3111
Mailing Address - Street 1:3300 E SOUTH ST STE 308
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4598
Mailing Address - Country:US
Mailing Address - Phone:562-630-3111
Mailing Address - Fax:562-630-3107
Practice Address - Street 1:11480 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241
Practice Address - Country:US
Practice Address - Phone:562-630-3111
Practice Address - Fax:562-630-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39222207RN0300X
207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093373Medicaid
CAW16145Medicare PIN