Basic Information
| Provider Information | |||||||||
| NPI: | 1366462293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUENA VISTA ANESTHESIA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266961132 | ||||||||
| FaxNumber: | 6263960851 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BUENA VISTA ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188435111 | ||||||||
| FaxNumber: | 8188473935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | ENGLUND | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL PARTNERSHIP | ||||||||
| AuthorizedOfficialTelephone: | 6266961124 | ||||||||
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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 | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0084040 | 05 | CA | MEDICAID | ZZZ57658Z | 01 | CA | BLUE SHIELD | OTHER |