Provider Demographics
NPI:1841334364
Name:INDEPENDENT ANESTHESIOLOGY, A MEDICAL GROUP
Entity type:Organization
Organization Name:INDEPENDENT ANESTHESIOLOGY, A MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-992-4444
Mailing Address - Street 1:PO BOX 10790
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-0790
Mailing Address - Country:US
Mailing Address - Phone:714-992-4444
Mailing Address - Fax:714-879-9999
Practice Address - Street 1:1001 N TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3502
Practice Address - Country:US
Practice Address - Phone:714-835-3555
Practice Address - Fax:714-953-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ47026ZOtherBLUE SHIELD
CAGR0066370Medicaid
CAW13637Medicare ID - Type Unspecified
CAZZZ47026ZOtherBLUE SHIELD