Provider Demographics
NPI:1912223983
Name:INTREPID ANESTHESIA ASSOCIATES CORPORATION
Entity Type:Organization
Organization Name:INTREPID ANESTHESIA ASSOCIATES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTRIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-903-1980
Mailing Address - Street 1:PO BOX 261070
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-1070
Mailing Address - Country:US
Mailing Address - Phone:310-903-1980
Mailing Address - Fax:818-880-9570
Practice Address - Street 1:427 W. PUEBLO ST.
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:91306
Practice Address - Country:US
Practice Address - Phone:310-903-1980
Practice Address - Fax:818-880-9570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG062996207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty