Basic Information
| Provider Information | |||||||||
| NPI: | 1548565245 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID SOUTH ANESTHESIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5000 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370885000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154442320 | ||||||||
| FaxNumber: | 6155479845 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154442320 | ||||||||
| FaxNumber: | 6155479845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2011 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 6154442320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | CRNA, MS, APN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0000058326 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.