Provider Demographics
NPI:1457423725
Name:SANTA MONICA ORTHOPAEDIC AND SPORTS MEDICINE GROUP
Entity Type:Organization
Organization Name:SANTA MONICA ORTHOPAEDIC AND SPORTS MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:RAMIN
Authorized Official - Last Name:MODABBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-829-2663
Mailing Address - Street 1:2020 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2023
Mailing Address - Country:US
Mailing Address - Phone:310-829-2663
Mailing Address - Fax:310-315-5620
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-829-2663
Practice Address - Fax:310-315-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA047467261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10633Medicare PIN
CA0496370002Medicare NSC