Basic Information
| Provider Information | |||||||||
| NPI: | 1366517583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ANESTHESIA OF DANVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 532904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303532904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174435000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 812 N LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618323752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174435000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 04/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOBOL | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2174435000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 09232012 | 01 | AZ | BCBS OF IL | OTHER | DA4244 | 01 | AZ | RAILROAD MEDICARE | OTHER |