Provider Demographics
NPI:1922112929
Name:SOUTHLAND ANESTHESIA MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHLAND ANESTHESIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-588-2190
Mailing Address - Street 1:26816 VISTA TER
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8115
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:
Practice Address - Street 1:725 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2614
Practice Address - Country:US
Practice Address - Phone:626-338-8481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43136207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43146EMedicare ID - Type Unspecified