Basic Information
| Provider Information | |||||||||
| NPI: | 1356449573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ANESTHESIA GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 WISPY WILLOW DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273326432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194982125 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 SAMARITANS RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | ELKIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286212457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368355330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAHOLTZ | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | CRNA | ||||||||
| AuthorizedOfficialTelephone: | 9102578460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.