Provider Demographics
NPI:1356362990
Name:THE ANESTHESIA MEDICAL GROUP INC
Entity type:Organization
Organization Name:THE ANESTHESIA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-962-3607
Mailing Address - Street 1:3626 RUFFIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 S BERETANIA ST
Practice Address - Street 2:SUITE 215
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1520
Practice Address - Country:US
Practice Address - Phone:808-532-3711
Practice Address - Fax:808-532-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI=========OtherBS HI
HI=========Medicaid