Healthcare Provider Details

I. General information

NPI: 1114177425
Provider Name (Legal Business Name): ANNADEL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DOYLE PARK DR SUITE 100
SANTA ROSA CA
95405-4558
US

IV. Provider business mailing address

1515 E ORANGEWOOD AVE SUITE 302
ANAHEIM CA
92805-6824
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-6090
  • Fax: 707-544-6694
Mailing address:
  • Phone: 714-449-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD E IGRAM
Title or Position: VICE PRESIDENT
Credential:
Phone: 714-937-6280