Healthcare Provider Details

I. General information

NPI: 1619050846
Provider Name (Legal Business Name): ANESTHESIA SPECIALISTS MEDICAL GROUP,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVENUE DOCTORS MEDICAL CENTER
MODESTO CA
95350
US

IV. Provider business mailing address

817 COFFEE ROAD C3
MODESTO CA
95355
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone: 209-529-9603
  • Fax: 209-529-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberG75791
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG75791
License Number StateCA

VIII. Authorized Official

Name: STEVEN JOHN THORUP
Title or Position: PRESIDENT
Credential: MD
Phone: 209-529-9603