Provider Demographics
NPI:1447306543
Name:LIGHTHOUSE ANESTHESIA MEDICAL GROUP
Entity type:Organization
Organization Name:LIGHTHOUSE ANESTHESIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAM-NGUYEN
Authorized Official - Middle Name:THI
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-636-0343
Mailing Address - Street 1:PO BOX 775
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-0775
Mailing Address - Country:US
Mailing Address - Phone:714-636-0343
Mailing Address - Fax:714-636-0391
Practice Address - Street 1:12601 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1908
Practice Address - Country:US
Practice Address - Phone:714-537-5160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81625174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G816250Medicaid
CA00G816250Medicaid