Provider Demographics
NPI:1649337221
Name:SOUTH COAST MEDICAL GROUP FAMILY AND SPORTS MEDICINE
Entity type:Organization
Organization Name:SOUTH COAST MEDICAL GROUP FAMILY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHERARDINI
Authorized Official - Suffix:
Authorized Official - Credentials:BSBA
Authorized Official - Phone:949-360-1069
Mailing Address - Street 1:5 JOURNEY STE 130
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5330
Mailing Address - Country:US
Mailing Address - Phone:949-360-1069
Mailing Address - Fax:949-389-8968
Practice Address - Street 1:5 JOURNEY STE 130
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5330
Practice Address - Country:US
Practice Address - Phone:949-360-1069
Practice Address - Fax:949-389-8968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619061397OtherJOHN CHENG, MD
CA1598723058OtherARCHANNA BHOGILL, MD
CA1861586554OtherSHANNON O'CONNOR, MD
CA1932284478OtherERIC CLARK, MD
CA1598723058OtherARCHANNA BHOGILL, MD
CAY06380Medicare UPIN