Basic Information
| Provider Information | |||||||||
| NPI: | 1790855161 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIDERE ANESTHESIA CONSULTANTS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FREMONT ANESTHESIA CONSULTANTS MEDICAL GROUP, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744653 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666784320 | ||||||||
| FaxNumber: | 6509039900 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 GRANT RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509039500 | ||||||||
| FaxNumber: | 6509039900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KAHTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AO | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0042170 | 05 | CA | MEDICAID | ZZZ18212Z | 01 | CA | BLUE SHIELD | OTHER |