Basic Information
| Provider Information | |||||||||
| NPI: | 1518924075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACWEST 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: | 6267959596 | ||||||||
| FaxNumber: | 7149180135 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900153010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137482411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | GIDAYA | ||||||||
| AuthorizedOfficialFirstName: | ERNESTO | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2137425401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A38770 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ504667Y | 01 | CA | BLUE SHIELD | OTHER | GR0103850 | 05 | CA | MEDICAID |