Provider Demographics
NPI:1871517557
Name:SO BAY UROLOGY MED GRP
Entity type:Organization
Organization Name:SO BAY UROLOGY MED GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:G
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-542-0199
Mailing Address - Street 1:20911 EARL ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4352
Mailing Address - Country:US
Mailing Address - Phone:310-542-0199
Mailing Address - Fax:310-542-4652
Practice Address - Street 1:20911 EARL ST STE 140
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4353
Practice Address - Country:US
Practice Address - Phone:310-542-0199
Practice Address - Fax:310-542-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1070Medicare ID - Type Unspecified