Basic Information
| Provider Information | |||||||||
| NPI: | 1205969748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAND RENAL MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E. SOUTH STREET | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908054598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626303111 | ||||||||
| FaxNumber: | 5626303107 | ||||||||
| Practice Location | |||||||||
| Address1: | 4152 KATELLA AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907206608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626303111 | ||||||||
| FaxNumber: | 5626303107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEMERJIAN | ||||||||
| AuthorizedOfficialFirstName: | AVEDIK | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5626303111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHLAND RENAL MEDICAL GROUP, INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/23/2020 | ||||||||
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 | GR0093371 | 05 | CA | MEDICAID |