Basic Information
| Provider Information | |||||||||
| NPI: | 1558333773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA ANESTHESIA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3380 | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037651838 | ||||||||
| FaxNumber: | 8037651732 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 NORTH WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034365582 | ||||||||
| FaxNumber: | 8034360085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ANESTHESIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 8037651838 | ||||||||
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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 | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GP0979 | 05 | SC | MEDICAID |