Provider Demographics
NPI:1619906310
Name:PIONEER ANESTHESIA GROUP INC
Entity Type:Organization
Organization Name:PIONEER ANESTHESIA GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUDHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-304-6796
Mailing Address - Street 1:PO BOX 3750
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3750
Mailing Address - Country:US
Mailing Address - Phone:888-304-6796
Mailing Address - Fax:801-432-2670
Practice Address - Street 1:3715 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5537
Practice Address - Country:US
Practice Address - Phone:888-304-6796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========007Medicaid
UT=========007Medicaid