1245388032 NPI number — ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC.

Table of content: (NPI 1245388032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245388032 NPI number — ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245388032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-0221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-580-6210
Provider Business Mailing Address Fax Number:
909-580-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N PEPPER AVE
Provider Second Line Business Practice Location Address:
SURGERY DEPARTMENT
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-580-6210
Provider Business Practice Location Address Fax Number:
909-580-1363
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GNANADEV
Authorized Official First Name:
APPANAGARI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-580-6210

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  51201 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00SP18300 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0079700 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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