Provider Demographics
NPI:1811060262
Name:WHITE MEMORIAL GYNECOLOGICAL AND OBSTETRICAL MEDICAL GROUP
Entity type:Organization
Organization Name:WHITE MEMORIAL GYNECOLOGICAL AND OBSTETRICAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:E. LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-225-4300
Mailing Address - Street 1:1701 E CESAR E CHAVEZ AVE
Mailing Address - Street 2:SUITES 200/225
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2464
Mailing Address - Country:US
Mailing Address - Phone:323-225-4300
Mailing Address - Fax:323-225-1803
Practice Address - Street 1:1701 E CESAR E CHAVEZ AVE
Practice Address - Street 2:SUITES 200/225
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2464
Practice Address - Country:US
Practice Address - Phone:323-225-4300
Practice Address - Fax:323-225-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25701525207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811060262OtherNPI
CAZZZ76811ZMedicaid
CA1811060262OtherNPI