Provider Demographics
NPI:1104872118
Name:LOMA LINDA UNIV ANESTHESIOLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:LOMA LINDA UNIV ANESTHESIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT LOMA LINDA UNIVERSITY ANE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-558-4143
Mailing Address - Street 1:FILE NUMBER 55799
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-5799
Mailing Address - Country:US
Mailing Address - Phone:800-326-6223
Mailing Address - Fax:909-558-4143
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4475
Practice Address - Fax:909-558-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030870Medicaid
CAZZZ19289ZMedicare ID - Type Unspecified