Basic Information
| Provider Information | |||||||||
| NPI: | 1619087319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ANESTHESIA ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660257 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352660257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 7191 CAHABA VALLEY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352426402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054089787 | ||||||||
| FaxNumber: | 2054083993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2052138420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 529921400 | 05 | AL | MEDICAID | DB7661 | 01 | AL | RAILROAD MEDICARE | OTHER |