Basic Information
Provider Information | |||||||||
NPI: | 1033464268 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED ANESTHESIA MEDICAL GROUP PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 80094 | ||||||||
Address2: |   | ||||||||
City: | CITY OF INDUSTRY | ||||||||
State: | CA | ||||||||
PostalCode: | 917168094 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103792134 | ||||||||
FaxNumber: | 3103794856 | ||||||||
Practice Location | |||||||||
Address1: | 800 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CORONA | ||||||||
State: | CA | ||||||||
PostalCode: | 928823420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103792134 | ||||||||
FaxNumber: | 3103794856 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2012 | ||||||||
LastUpdateDate: | 05/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDWARDS | ||||||||
AuthorizedOfficialFirstName: | IRV | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3103792434 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 05/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | A66108 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.