Basic Information
| Provider Information | |||||||||
| NPI: | 1689795312 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC PALISADES SURGERY CENTER AND MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | PACIFIC SURGERY CENTER OF SANTA MONICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 SANTA MONICA BLVD STE 724E | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108299060 | ||||||||
| FaxNumber: | 3108299015 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE 724E | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108299060 | ||||||||
| FaxNumber: | 3108299015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | BOXRUD | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3108299060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | S051575 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.