Basic Information
| Provider Information | |||||||||
| NPI: | 1366479644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-STAR ANESTHESIA P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16068 | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272616068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368824615 | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 25TH AVE N | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153299023 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6153299023 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Pain Management |
ID Information
| ID | Type | State | Issuer | Description | 3632631 | 05 | TN | MEDICAID |