Basic Information
| Provider Information | |||||||||
| NPI: | 1609880947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ANESTHESIA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 21ST ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933013108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613341958 | ||||||||
| FaxNumber: | 6613244095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 21ST ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933013108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613341958 | ||||||||
| FaxNumber: | 6613244095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | HICKS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6613341958 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0084983 | 05 | CA | MEDICAID | GR0084981 | 05 | CA | MEDICAID | GR0084980 | 05 | CA | MEDICAID | GR0084982 | 05 | CA | MEDICAID |