Provider Demographics
NPI:1871641571
Name:MID COUNTY SURGICAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MID COUNTY SURGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CAMARA
Authorized Official - Last Name:ANANE-SEFAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-476-5403
Mailing Address - Street 1:603 CAPITOLA AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2751
Mailing Address - Country:US
Mailing Address - Phone:831-476-5403
Mailing Address - Fax:831-476-4107
Practice Address - Street 1:603 CAPITOLA AVE
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2751
Practice Address - Country:US
Practice Address - Phone:831-476-5403
Practice Address - Fax:831-476-4107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23854208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030290Medicaid
CAG23854OtherMD JOHN C. ANANE-SEFAH
CAG23854OtherMD JOHN C. ANANE-SEFAH
AA7563249OtherDEA JOHN C. ANANE-SEFAH
CAG23854OtherMD JOHN C. ANANE-SEFAH
=========OtherEIN