Provider Demographics
NPI:1205969748
Name:SOUTHLAND RENAL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SOUTHLAND RENAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:AVEDIK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEMERJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-630-3111
Mailing Address - Street 1:3300 E. SOUTH STREET
Mailing Address - Street 2:SUITE 308
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4598
Mailing Address - Country:US
Mailing Address - Phone:562-630-3111
Mailing Address - Fax:562-630-3107
Practice Address - Street 1:4152 KATELLA AVE STE 201
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-6608
Practice Address - Country:US
Practice Address - Phone:562-630-3111
Practice Address - Fax:562-630-3107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAND RENAL MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-13
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46344207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093371Medicaid
CAW16145AMedicare PIN