Provider Demographics
NPI:1821040411
Name:MADERA ANESTHESIA ASSOC MED GRP
Entity Type:Organization
Organization Name:MADERA ANESTHESIA ASSOC MED GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GRP PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:YANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-675-5555
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 1:1250 E ALMOND
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637
Practice Address - Country:US
Practice Address - Phone:559-675-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ53447ZOtherBLUE SHIELD OF CALIFORNIA
CAGR0071410Medicaid
CADF5609Medicare PIN
CAZZZ13631ZMedicare PIN
CAZZZ04389ZMedicare PIN