Basic Information
| Provider Information | |||||||||
| NPI: | 1619050846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA SPECIALISTS MEDICAL GROUP,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 817 COFFEE ROAD | ||||||||
| Address2: | C3 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095299603 | ||||||||
| FaxNumber: | 2095296610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 FLORIDA AVENUE | ||||||||
| Address2: | DOCTORS MEDICAL CENTER | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095781211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 12/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | THORUP | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2095299603 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | G75791 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | G75791 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0102320 | 05 | CA | MEDICAID |