Provider Demographics
NPI:1073531836
Name:SOUTH BAY ANESTHESIA MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:SOUTH BAY ANESTHESIA MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WYMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-0601
Mailing Address - Street 1:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:714-619-5387
Mailing Address - Fax:707-701-6662
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-540-7676
Practice Address - Fax:310-540-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076760Medicaid
CAZZZ53133ZOtherBLUE SHIELD
CAGR0076760Medicaid