Basic Information
| Provider Information | |||||||||
| NPI: | 1093153538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUWANEE ANESTHESIA SERVICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 629 | ||||||||
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| City: | PERRY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310690629 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3858 SHADOW LOCH DR | ||||||||
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| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300247003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789290036 | ||||||||
| FaxNumber: | 4789291744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2013 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4789290036 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN054969 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.