Basic Information
| Provider Information | |||||||||
| NPI: | 1699784959 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEPHEN M. FERNANDEZ M.D.,INC., A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S LAKE AVE | ||||||||
| Address2: | 535 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911013005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 6267958247 | ||||||||
| Practice Location | |||||||||
| Address1: | 614 W DUARTE RD | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910077601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264454714 | ||||||||
| FaxNumber: | 6264451701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3233085548 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G480051 | 05 | CA | MEDICAID | 00G480051 | 01 | CA | BLUE SHIELD | OTHER |