Healthcare Provider Details

I. General information

NPI: 1578599619
Provider Name (Legal Business Name): MAD RIVER COMMUNITY ANESTHESIA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 JANES RD
ARCATA CA
95521-4742
US

IV. Provider business mailing address

PO BOX 1115
ARCATA CA
95518-1115
US

V. Phone/Fax

Practice location:
  • Phone: 707-822-7250
  • Fax: 707-826-8258
Mailing address:
  • Phone: 707-822-7250
  • Fax: 707-826-8258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J YOUNG
Title or Position: C.F.O.
Credential:
Phone: 707-826-8203