Basic Information
| Provider Information | |||||||||
| NPI: | 1518542919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SE GEORGIA ANESTHESIA, LLC | ||||||||
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| OtherOrganizationName: | MEMORIAL HEALTH MEADOWS PHYSICIANS- ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5295 WESTVIEW DR STE 225 | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882761910 | ||||||||
| FaxNumber: | 7707016716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEADOWS PKWY | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882761910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | FAILE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ALI | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8882761910 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.