Provider Demographics
NPI:1558588871
Name:PEDIATRIC ANESTHESIA ASSOCIATES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PEDIATRIC ANESTHESIA ASSOCIATES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-449-4350
Mailing Address - Street 1:6235 N FRESNO ST
Mailing Address - Street 2:SUITE #103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5269
Mailing Address - Country:US
Mailing Address - Phone:559-449-4350
Mailing Address - Fax:559-449-4358
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207L00000X
207LP3000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Single Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ71868ZMedicaid
CAZZZ71868ZMedicare ID - Type UnspecifiedMEDICARE
CAZZZ71868ZMedicaid