Basic Information
| Provider Information | |||||||||
| NPI: | 1831106905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APPLE VALLEY ANESTHESIA MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S 1ST ST | ||||||||
| Address2: | 1000 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915021938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188456206 | ||||||||
| FaxNumber: | 8188459774 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 HWY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923072206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
| FaxNumber: | 7602429167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DE ASIS | ||||||||
| AuthorizedOfficialFirstName: | BENILDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7609463210 | ||||||||
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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 | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0091390 | 05 | CA | MEDICAID | ZZZ03117Z | 01 | CA | BLUE SHIELD | OTHER |