Basic Information
| Provider Information | |||||||||
| NPI: | 1104828086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXCEL ANESTHESIA PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423201553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702740480 | ||||||||
| FaxNumber: | 2702740482 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423201553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702740480 | ||||||||
| FaxNumber: | 2702740482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2702740480 | ||||||||
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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 | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 74904137 | 05 | KY | MEDICAID |