Basic Information
| Provider Information | |||||||||
| NPI: | 1073531836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY ANESTHESIA MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146195387 | ||||||||
| FaxNumber: | 7077016662 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 TORRANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905034607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105407676 | ||||||||
| FaxNumber: | 3105401485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | WYMORE | ||||||||
| AuthorizedOfficialFirstName: | DWIGHT | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3107920601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0076760 | 05 | CA | MEDICAID | ZZZ53133Z | 01 | CA | BLUE SHIELD | OTHER |