Provider Demographics
NPI:1881642692
Name:SAN PABLO ANESTHESIOLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SAN PABLO ANESTHESIOLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MERTON
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-372-2740
Mailing Address - Street 1:8905 SW NIMBUS AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7136
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:2000 VALE RD
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3808
Practice Address - Country:US
Practice Address - Phone:510-970-5000
Practice Address - Fax:510-970-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ22864ZMedicare ID - Type Unspecified