Basic Information
| Provider Information | |||||||||
| NPI: | 1255398343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMADOR ANESTHESIA MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092237500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | HASSON | ||||||||
| AuthorizedOfficialFirstName: | GRANT | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2092237500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ644662 | 01 | CA | BLUE SHIELD | OTHER | GR0099110 | 05 | CA | MEDICAID | 607575600 | 01 | CA | US DEPT OF LABOR | OTHER | DC9710 | 01 | CA | RAILROAD MEDICARE | OTHER |