Basic Information
| Provider Information | |||||||||
| NPI: | 1336199645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYVILLE ANESTHESIOLOGISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3181 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553810344 | ||||||||
| FaxNumber: | 8007310751 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659837211 | ||||||||
| FaxNumber: | 8559172023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | COLEMAN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8659837211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CL8433 | 01 | TN | RR | OTHER | 3378283 | 05 | TN | MEDICAID | 3604498 | 05 | TN | MEDICAID |