Basic Information
Provider Information | |||||||||
NPI: | 1992838429 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHLAND RENAL MEDICAL GROUP, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 11480 BROOKSHIRE AVE | ||||||||
Address2: | SUITE 110 | ||||||||
City: | DOWNEY | ||||||||
State: | CA | ||||||||
PostalCode: | 90241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626303111 | ||||||||
FaxNumber: | 5626303107 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2007 | ||||||||
LastUpdateDate: | 08/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FISCHMAN | ||||||||
AuthorizedOfficialFirstName: | CORA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 5626303111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | G39222 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | GR0093373 | 05 | CA |   | MEDICAID |