Provider Demographics
NPI:1669407839
Name:ANESTHESIA MEDICAL GROUP OF RIVERSIDE, INC
Entity type:Organization
Organization Name:ANESTHESIA MEDICAL GROUP OF RIVERSIDE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-686-3575
Mailing Address - Street 1:6969 BROCKTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3813
Mailing Address - Country:US
Mailing Address - Phone:951-686-3575
Mailing Address - Fax:951-781-2194
Practice Address - Street 1:6969 BROCKTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3813
Practice Address - Country:US
Practice Address - Phone:951-686-3575
Practice Address - Fax:951-781-2194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ207762Medicaid
CAZZZ20776ZMedicare PIN
CACQ2052Medicare PIN
CAZZZ20776ZMedicare ID - Type UnspecifiedGROUP MEDICARE