Provider Demographics
NPI:1073997359
Name:SOUTHERN CALIFORNIA GASTROENTEROLOGY ANESTHESIA SPECIA
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA GASTROENTEROLOGY ANESTHESIA SPECIA
Other - Org Name:SOUTHERN CALIFORNIA GASTROENTEROLOGY ANESTHESIA SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:619-857-8764
Mailing Address - Street 1:286 EUCLID AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-3611
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:286 EUCLID AVE
Practice Address - Street 2:SUITE #109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3610
Practice Address - Country:US
Practice Address - Phone:619-266-1653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB241276Medicare PIN