Basic Information
| Provider Information | |||||||||
| NPI: | 1720401284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACSOLANO ANESTHESIA EXCHANGE MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660910 | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958660910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164816800 | ||||||||
| FaxNumber: | 9164811881 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 WATT AVE | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958213600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164816800 | ||||||||
| FaxNumber: | 9164811881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2014 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | HALLUM | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9164816800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D., D.O | ||||||||
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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 |
No ID Information.