NPIMap

Organization Active NPI

Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Fontana, CA
National Provider Identifier
1689606196
Registry record updated Nov 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Health Maintenance OrganizationTaxonomy code 302R00000X
Legal business name
SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Practice address
9961 Sierra Ave
Fontana, CA 92335-6720
Phone
(909) 427-3910
NPI assigned
Jul 7, 2006
Last updated
Nov 2, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 2, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ramin Davidoff, MD
Title
Executive Medical Director
Phone
(877) 608-0044

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Health Maintenance Organization 302R00000X Primary

Addresses

Primary practice location

9961 Sierra Ave
Fontana, CA 92335-6720

Mailing address

393 E Walnut St
3Rd FL PHR Group & Provider Enrollment
Pasadena, CA 91188-0001
Phone (626) 405-7914

Other identifiers 1

IdentifierTypeStateIssuer
ZZZ41545ZMedicaidCA

Electronic endpoints 1

TypeEndpointUseAffiliation
SOAP URL https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq Health Information Exchange (HIE)

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040126000823 CA Part B Supplier - Clinic/Group Practice 6002729175 Receives reassigned benefits from 5,496 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
O20260217001864 CA MDPP Supplier - in-Person MDPP Supplier With Distance Learning 6002729175 12 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 17

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 17

National Provider Directory

National Provider Directory

Locations

3733 San Dimas St
Ste 101
Bakersfield, CA 93301
Phone (800) 353-5400

3750 Grand Ave
Chino, CA 91710
Phone (909) 902-2929

9310 Sierra Ave
Fontana, CA 92335
Phone (909) 427-3700

5330 San Bernardino St
Montclair, CA 91763
Phone (909) 399-3700

5225 Canyon Crest Dr
Riverside, CA 92507
Phone (951) 686-2203

13993 Park Ave
Victorville, CA 92392

Practitioners & affiliated clinicians

Practitioners 2,078

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 2,078

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152230400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635811200000",
    "number": "1689606196",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "393 E WALNUT ST",
            "address_2": "3RD FL PHR GROUP & PROVIDER ENROLLMENT",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911880001",
            "telephone_number": "626-405-7914",
            "fax_number": "626-405-4600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9961 SIERRA AVE",
            "city": "FONTANA",
            "state": "CA",
            "postal_code": "923356720",
            "telephone_number": "909-427-3910"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-07",
        "last_updated": "2021-11-02",
        "certification_date": "2021-11-02",
        "status": "A",
        "authorized_official_last_name": "DAVIDOFF",
        "authorized_official_first_name": "RAMIN",
        "authorized_official_title_or_position": "EXECUTIVE MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "877-608-0044",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "302R00000X",
            "taxonomy_group": "",
            "desc": "Health Maintenance Organization",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZZ41545Z",
            "state": "CA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "N",
            "endpointDescription": "Carequality",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "9961 Sierra Ave",
            "city": "Fontana",
            "state": "CA",
            "country_code": "US",
            "postal_code": "923356720",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Fontana, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.