Basic Information
| Provider Information | |||||||||
| NPI: | 1578163770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ANESTHESIA, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 293151 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372293151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
| FaxNumber: | 6156202323 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707815111 | ||||||||
| FaxNumber: | 2707800478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEMAREE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6158655561 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.