Basic Information
| Provider Information | |||||||||
| NPI: | 1164535571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT ANESTHESIA MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S 1ST ST | ||||||||
| Address2: | 1000 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915021938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188456206 | ||||||||
| FaxNumber: | 8188459774 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134847111 | ||||||||
| FaxNumber: | 2134845525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8188456206 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0101590 | 05 | CA | MEDICAID | ZZZ65160Z | 01 | CA | BLUE SHIELD | OTHER |