Provider Demographics
NPI:1609880947
Name:PREMIER ANESTHESIA MEDICAL GROUP
Entity Type:Organization
Organization Name:PREMIER ANESTHESIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-334-1958
Mailing Address - Street 1:3200 21ST ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-3108
Mailing Address - Country:US
Mailing Address - Phone:661-334-1958
Mailing Address - Fax:661-324-4095
Practice Address - Street 1:3200 21ST ST STE 301
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-3108
Practice Address - Country:US
Practice Address - Phone:661-334-1958
Practice Address - Fax:661-324-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084983Medicaid
CAGR0084981Medicaid
CAGR0084980Medicaid
CAGR0084982Medicaid
CADF013AMedicare PIN
CAZZZ15998ZMedicare PIN
CAGR0084980Medicaid
CAGR0084981Medicaid
CAZZZ21367ZMedicare PIN
CACB232922Medicare PIN
CAGR0084983Medicaid
CAGR0084982Medicaid
CAZZZ34009ZMedicare PIN
CAZZZ15999ZMedicare PIN
CACD4582Medicare PIN