1578599619 NPI number — MAD RIVER COMMUNITY ANESTHESIA MEDICAL GROUP

Table of content: (NPI 1578599619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578599619 NPI number — MAD RIVER COMMUNITY ANESTHESIA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAD RIVER COMMUNITY 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:
1578599619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCATA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95518-1115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-822-7250
Provider Business Mailing Address Fax Number:
707-826-8258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 JANES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCATA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95521-4742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-822-7250
Provider Business Practice Location Address Fax Number:
707-826-8258
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
C.F.O.
Authorized Official Telephone Number:
707-826-8203

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com