Basic Information
| Provider Information | |||||||||
| NPI: | 1861617045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COAST PERINATAL MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6272 | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931606272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058980258 | ||||||||
| FaxNumber: | 8058982048 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 W PUEBLO ST STE A | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058980258 | ||||||||
| FaxNumber: | 8058982048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | SOFFICI | ||||||||
| AuthorizedOfficialFirstName: | ALEJANDRO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8058980258 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | G65077 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1861617045 | 05 | CA | MEDICAID |