Provider Demographics
NPI:1508871385
Name:VERDUGO HILLS ANESTHESIA MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:VERDUGO HILLS ANESTHESIA MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCILVENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-795-6596
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:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:1812 VERDUGO BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1407
Practice Address - Country:US
Practice Address - Phone:818-952-2214
Practice Address - Fax:818-952-4618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2015-03-25
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
CAZZZ36723ZOtherBLUE SHIELD
CAGR0055000Medicaid
CAGR0055000Medicaid