Basic Information
| Provider Information | |||||||||
| NPI: | 1538272141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JESUPCARE ANESTHESIA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2585 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319022585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 865 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315450210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124276811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 01/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | DIAMANT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7066608505 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.