Basic Information
| Provider Information | |||||||||
| NPI: | 1114177425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANNADEL MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 E ORANGEWOOD AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928056824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 DOYLE PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075446090 | ||||||||
| FaxNumber: | 7075446694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 05/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | IGRAM | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7149376280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.