Basic Information
| Provider Information | |||||||||
| NPI: | 1154876852 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GS MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
| FaxNumber: | 8003376311 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 S AVERILL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907323813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4242068336 | ||||||||
| FaxNumber: | 8003376311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2016 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4242068336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GS MEDICAL CENTER INC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | A50680 | CA | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.