Provider Demographics
NPI:1245388032
Name:ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:APPANAGARI
Authorized Official - Middle Name:
Authorized Official - Last Name:GNANADEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-580-6210
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0221
Mailing Address - Country:US
Mailing Address - Phone:909-580-6210
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:SURGERY DEPARTMENT
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6210
Practice Address - Fax:909-580-1363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51201204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00SP18300Medicaid
CAGR0079700Medicaid
CA00SP18300Medicaid
CAGR0079700Medicaid