1912936709 NPI number — SIMI VALLEY ANESTHESIA MEDICAL GROUP

Table of content: (NPI 1912936709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912936709 NPI number — SIMI VALLEY ANESTHESIA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIMI VALLEY ANESTHESIA MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912936709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80598
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CITY OF INDUSTRY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91716-8409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-792-3914
Provider Business Mailing Address Fax Number:
855-898-4055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2975 SYCAMORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIMI VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93065-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-792-3914
Provider Business Practice Location Address Fax Number:
855-898-4055
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHU
Authorized Official First Name:
KYO
Authorized Official Middle Name:
YONG
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
310-792-3914

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0089730 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ01551Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com