=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437221595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRAMENTO ANESTHESIA MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3939 J ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-733-6996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3315 WATT AVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95821-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-481-0777
-----------------------------------------------------
Fax | 916-977-1265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PAUL JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-733-6996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 84509
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------