Basic Information
| Provider Information | |||||||||
| NPI: | 1073632600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ANESTHESIA ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724928 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311399028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788381585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 ALCOVY ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306552140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788381585 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | RIGDON | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 6788381585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GRP6349 | 01 | MEDICARE GROUP NUMBER | OTHER |