Basic Information
| Provider Information | |||||||||
| NPI: | 1679837645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VENTURA COUNTY ANESTHESIA MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3116 W MARCH LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952192369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094736555 | ||||||||
| FaxNumber: | 2094736544 | ||||||||
| Practice Location | |||||||||
| Address1: | 3291 LOMA VISTA RD | ||||||||
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| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930033099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056526000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2012 | ||||||||
| LastUpdateDate: | 08/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | FISHMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE INCORPORATOR | ||||||||
| AuthorizedOfficialTelephone: | 8056526000 | ||||||||
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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 | 207L00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1679837645 | 05 | CA | MEDICAID |