Basic Information
| Provider Information | |||||||||
| NPI: | 1619447828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC | ||||||||
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| OtherOrganizationName: | FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603366 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131500 | ||||||||
| FaxNumber: | 8286811575 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 LONG SHOALS RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287048794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2018 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | TATHAM | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8286516595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02CG9 | 01 | NC | BC/BS NC | OTHER |