Healthcare Provider Details

I. General information

NPI: 1255504270
Provider Name (Legal Business Name): LOS ANGELES ANESTHESIA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

IV. Provider business mailing address

3420 BRISTOL ST STE 750
COSTA MESA CA
92626-1996
US

V. Phone/Fax

Practice location:
  • Phone: 949-588-2190
  • Fax: 949-588-2199
Mailing address:
  • Phone: 714-432-1438
  • Fax: 949-588-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG64633
License Number StateCA

VIII. Authorized Official

Name: THOMAS JEFFREY TAKASH
Title or Position: PRESIDENT
Credential: MD
Phone: 949-588-2190