Provider Demographics
NPI:1710179189
Name:CARMEL HEALTHCARE ANESTHESIA MEDICAL PROVIDERS INC
Entity Type:Organization
Organization Name:CARMEL HEALTHCARE ANESTHESIA MEDICAL PROVIDERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-333-4000
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:2 UPPER RAGSDALE DR
Practice Address - Street 2:BLDG B, STE B160
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5736
Practice Address - Country:US
Practice Address - Phone:831-333-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ62741ZOtherBLUE SHIELD OF CA
CAZZZ62742ZOtherBLUE SHIELD OF CA
CAGR0105420Medicaid
CAZZZ627402OtherBLUE SHIELD OF CA
CAGR0105420Medicaid