Provider Demographics
NPI:1255398343
Name:AMADOR ANESTHESIA MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:AMADOR ANESTHESIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-223-7500
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:200 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642
Practice Address - Country:US
Practice Address - Phone:209-223-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ644662OtherBLUE SHIELD
CAGR0099110Medicaid
CA607575600OtherUS DEPT OF LABOR
CADC9710OtherRAILROAD MEDICARE
CADC9710OtherRAILROAD MEDICARE