Basic Information
| Provider Information | |||||||||
| NPI: | 1912920331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITRUS VALLEY ANESTHESIA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262046747 | ||||||||
| FaxNumber: | 6263960851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269624011 | ||||||||
| FaxNumber: | 6268595873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | SENTHILKUMAR | ||||||||
| AuthorizedOfficialFirstName: | NADARAJAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6264412017 | ||||||||
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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 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ07004Z | 01 | CA | BLUE SHIELD | OTHER | GR0093950 | 05 | CA | MEDICAID |