Provider Demographics
NPI:1861559544
Name:SANTA MONICA GYNECOLOGICAL AND OBSTECTRICAL MEDICAL GROUP INCORPORATED
Entity type:Organization
Organization Name:SANTA MONICA GYNECOLOGICAL AND OBSTECTRICAL MEDICAL GROUP INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-828-8585
Mailing Address - Street 1:1301 20TH ST
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2050
Mailing Address - Country:US
Mailing Address - Phone:310-828-8585
Mailing Address - Fax:310-453-4844
Practice Address - Street 1:1301 20TH ST
Practice Address - Street 2:SUITE 270
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-828-8585
Practice Address - Fax:310-453-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW4297Medicare ID - Type Unspecified