Provider Demographics
NPI:1336157411
Name:PRIMERO ANESTHESIA SERVICES MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PRIMERO ANESTHESIA SERVICES MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAMILO
Authorized Official - Middle Name:QUITA
Authorized Official - Last Name:PRIMERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-560-1580
Mailing Address - Street 1:500 S MAIN ST
Mailing Address - Street 2:1210
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4507
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:714-560-1585
Practice Address - Street 1:150 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6207
Practice Address - Country:US
Practice Address - Phone:626-335-0231
Practice Address - Fax:626-335-5082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A311701OtherBLUE SHIELD
CA00A311701Medicaid
CA00A311701Medicaid
CAW20839Medicare PIN