Provider Demographics
NPI:1821186776
Name:JP ANESTHESIOLOGY, INC
Entity Type:Organization
Organization Name:JP ANESTHESIOLOGY, INC
Other - Org Name:ADVANCED PAIN MANAGEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-843-9679
Mailing Address - Street 1:15447 WEST SAND STREET
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-4500
Mailing Address - Country:US
Mailing Address - Phone:760-843-9679
Mailing Address - Fax:760-245-3618
Practice Address - Street 1:15447 W SAND ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2904
Practice Address - Country:US
Practice Address - Phone:760-843-9679
Practice Address - Fax:760-245-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86588207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A865880Medicaid
CAZZZ02746ZOtherPTAN
CADF4286OtherMEDICARE RAILROAD
CABP8350100OtherDEA
CAI16538Medicare UPIN