Basic Information
| Provider Information | |||||||||
| NPI: | 1821171729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONEJO LOS ROBLES ANESTHESIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055788950 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 W JANSS RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913601847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053704521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | WIESE | ||||||||
| AuthorizedOfficialFirstName: | MOGENS | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8053704521 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
No ID Information.