Provider Demographics
NPI:1366500571
Name:GROSSMONT ANESTHESIA SERVICES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GROSSMONT ANESTHESIA SERVICES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOURAJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-460-5111
Mailing Address - Street 1:8893 LA MESA BLVD SUITE D
Mailing Address - Street 2:PO BOX 3617
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-3617
Mailing Address - Country:US
Mailing Address - Phone:619-460-5111
Mailing Address - Fax:619-460-7815
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-456-0711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064000Medicaid
W13408Medicare ID - Type Unspecified