=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912223819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC ANESTHESIA GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2010
-----------------------------------------------------
Last Update Date | 04/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16260 VENTURA BLVD STE 800
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 241295
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-1295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PRESIDENT
-----------------------------------------------------
Name | DR. JONATHAN FARSHAD KOHAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-788-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------