Basic Information
| Provider Information | |||||||||
| NPI: | 1508871385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VERDUGO HILLS ANESTHESIA MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 6267958247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1812 VERDUGO BLVD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912081407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189522214 | ||||||||
| FaxNumber: | 8189524618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCILVENA | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6267956596 | ||||||||
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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 | 207L00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ36723Z | 01 | CA | BLUE SHIELD | OTHER | GR0055000 | 05 | CA | MEDICAID |