Basic Information
| Provider Information | |||||||||
| NPI: | 1467406603 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHASTA ANESTHESIA CONSULTANTS A MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1134 PINE ST | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302213727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302256000 | ||||||||
| FaxNumber: | 5302430445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | MOON | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5302257100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G80229 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0054920 | 05 | CA | MEDICAID |