Basic Information
| Provider Information | |||||||||
| NPI: | 1427080480 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TWIN CITY ANESTHESIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANESTHESIA ASSOCIATES OF MONROE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 SHERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183238887 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 MCMILLAN RD | ||||||||
| Address2: | |||||||||
| City: | WEST MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712915327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183238887 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAYS | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8476152200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1026778 | 05 | LA | MEDICAID |