Basic Information
| Provider Information | |||||||||
| NPI: | 1447306543 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTHOUSE ANESTHESIA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775 | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928420775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146360343 | ||||||||
| FaxNumber: | 7146360391 | ||||||||
| Practice Location | |||||||||
| Address1: | 12601 GARDEN GROVE BLVD | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928431908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145375160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | PHAM | ||||||||
| AuthorizedOfficialFirstName: | TAM-NGUYEN | ||||||||
| AuthorizedOfficialMiddleName: | THI | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7146360343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G81625 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00G816250 | 05 | CA | MEDICAID |