Healthcare Provider Details

I. General information

NPI: 1518924075
Provider Name (Legal Business Name): PACWEST ANESTHESIA MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S GRAND AVE
LOS ANGELES CA
90015-3010
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 213-748-2411
  • Fax:
Mailing address:
  • Phone: 626-795-9596
  • Fax: 714-918-0135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA38770
License Number StateCA

VIII. Authorized Official

Name: ERNESTO P GIDAYA JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 213-742-5401