Basic Information
| Provider Information | |||||||||
| NPI: | 1154569523 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC COAST ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4790 IRVINE BLVD STE 105-355 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926201973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882199 | ||||||||
| Practice Location | |||||||||
| Address1: | 4790 IRVINE BLVD STE 105-355 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926201973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 01/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | STANLEY | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9495882190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 27940 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | NA27940 | 01 | CA | PROCESSING | OTHER |