Healthcare Provider Details

I. General information

NPI: 1538490230
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY OF MONTEREY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GARDEN ROAD SUITE 110 PEDIATRIC GROUP OF MONTEREY
MONTEREY CA
93940
US

IV. Provider business mailing address

PO BOX 204
PEBBLE BEACH CA
93953
US

V. Phone/Fax

Practice location:
  • Phone: 831-626-3259
  • Fax: 888-860-1110
Mailing address:
  • Phone: 831-626-3259
  • Fax: 888-860-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA52400
License Number StateCA

VIII. Authorized Official

Name: DR. ANDERS KARL DAHLSTROM
Title or Position: PRESIDENT (OF CORPORATION)/CEO
Credential: M.D. PH.D.
Phone: 831-626-3259