Basic Information
| Provider Information | |||||||||
| NPI: | 1134252679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAND RENAL MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E SOUTH ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908054598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626303111 | ||||||||
| FaxNumber: | 5626303107 | ||||||||
| Practice Location | |||||||||
| Address1: | 18111 BROOKHURST ST STE 6700 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626303111 | ||||||||
| FaxNumber: | 5626303107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | FISCHMAN | ||||||||
| AuthorizedOfficialFirstName: | CORA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5626303111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | A46344 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | GR0093374 | 05 | CA | MEDICAID |