Provider Demographics
NPI:1659320984
Name:ANESTHESIA & ANALGESIA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ANESTHESIA & ANALGESIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:N
Authorized Official - Last Name:TIBBETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-372-2740
Mailing Address - Street 1:PO BOX 49246
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-9246
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:837 5TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4526
Practice Address - Country:US
Practice Address - Phone:707-522-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0049070Medicaid
CAZZZ05515ZMedicare PIN
CAGR0049070Medicaid