Healthcare Provider Details

I. General information

NPI: 1629078589
Provider Name (Legal Business Name): SAN GABRIEL VALLEY SURGICAL MEDICAL GRP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W COVINA BLVD SUITE 101
SAN DIMAS CA
91773-3200
US

IV. Provider business mailing address

1330 W COVINA BLVD SUITE 101
SAN DIMAS CA
91773-3200
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-6784
  • Fax: 909-599-7073
Mailing address:
  • Phone: 909-599-6784
  • Fax: 909-599-7073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG6999
License Number StateCA

VIII. Authorized Official

Name: DR. MARK FREDERICK ANAPOELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-599-6784