Provider Demographics
NPI:1538490230
Name:PEDIATRIC GASTROENTEROLOGY OF MONTEREY INC.
Entity Type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY OF MONTEREY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT (OF CORPORATION)/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDERS
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:DAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:831-626-3259
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:PEBBLE BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93953
Mailing Address - Country:US
Mailing Address - Phone:831-626-3259
Mailing Address - Fax:888-860-1110
Practice Address - Street 1:1900 GARDEN ROAD SUITE 110
Practice Address - Street 2:PEDIATRIC GROUP OF MONTEREY
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940
Practice Address - Country:US
Practice Address - Phone:831-626-3259
Practice Address - Fax:888-860-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA524002080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52400OtherCALIFORNIA STATE LICENCE