Healthcare Provider Details

I. General information

NPI: 1932742905
Provider Name (Legal Business Name): PROFESSIONAL ANESTHESIA ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W 7TH ST
SAN PEDRO CA
90732-3505
US

IV. Provider business mailing address

PO BOX 1123
JACKSON MI
49204-1123
US

V. Phone/Fax

Practice location:
  • Phone: 310-832-3311
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MIDHAT QIDWAI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 310-548-5161