Basic Information
| Provider Information | |||||||||
| NPI: | 1245388032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
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| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923730221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095806210 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | SURGERY DEPARTMENT | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095806210 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GNANADEV | ||||||||
| AuthorizedOfficialFirstName: | APPANAGARI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9095806210 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | 51201 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00SP18300 | 05 | CA | MEDICAID | GR0079700 | 05 | CA | MEDICAID |