Basic Information
| Provider Information | |||||||||
| NPI: | 1063554798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENT ANESTHESIA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5486 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928635486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | WEST HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913071902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | HERBERT | ||||||||
| AuthorizedOfficialFirstName: | A JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8185500900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G46241 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ56463Z | 01 | CA | BLUE SHIELD | OTHER | GR0083620 | 05 | CA | MEDICAID |