Provider Demographics
NPI:1063554798
Name:PROVIDENT ANESTHESIA MEDICAL GROUP INC
Entity type:Organization
Organization Name:PROVIDENT ANESTHESIA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:A JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:HERBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-550-0900
Mailing Address - Street 1:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:505-293-1524
Practice Address - Street 1:7300 MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1902
Practice Address - Country:US
Practice Address - Phone:818-550-0900
Practice Address - Fax:505-293-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46241207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ56463ZOtherBLUE SHIELD
CAGR0083620Medicaid
CAZZZ56463ZOtherBLUE SHIELD