Basic Information
| Provider Information | |||||||||
| NPI: | 1205165065 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSONVILLE ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 PELHAM RD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362653369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564354970 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2009 | ||||||||
| LastUpdateDate: | 12/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | CLEMENS | ||||||||
| AuthorizedOfficialFirstName: | ROB | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6608265960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD PHD | ||||||||
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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 |
No ID Information.