Basic Information
| Provider Information | |||||||||
| NPI: | 1427014091 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA ANESTHESIA GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4331 | ||||||||
| Address2: | |||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903094331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104063760 | ||||||||
| FaxNumber: | 3103037944 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 W 7TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907323505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108323311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | GROSS | ||||||||
| AuthorizedOfficialFirstName: | MAURICE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104063760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ64632Z | 01 | CA | BLUE SHIELD | OTHER |