Basic Information
| Provider Information | |||||||||
| NPI: | 1558728907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST SOURCE ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 | ||||||||
| Address2: | DEPT #249 | ||||||||
| City: | ORLANDA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328850249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887280882 | ||||||||
| FaxNumber: | 8885121507 | ||||||||
| Practice Location | |||||||||
| Address1: | 577 MULBERRY ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312018220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887280882 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2016 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOUBERLY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8887280882 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.