Basic Information
Provider Information | |||||||||
NPI: | 1871775783 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MK JEFFERSON MD ANESTHESIA SERVICS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10076 | ||||||||
Address2: |   | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914100076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055788300 | ||||||||
FaxNumber: | 8055788950 | ||||||||
Practice Location | |||||||||
Address1: | 18300 ROSCOE BLVD | ||||||||
Address2: |   | ||||||||
City: | NORTHRIDGE | ||||||||
State: | CA | ||||||||
PostalCode: | 913254105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188858500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2007 | ||||||||
LastUpdateDate: | 12/03/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JEFFERSON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8188858500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | G68903C | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | G68903C | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 00G689030 | 01 | CA | BLUE SHIELD | OTHER |