Basic Information
| Provider Information | |||||||||
| NPI: | 1649229014 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHENS ANESTHESIA ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
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| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373710220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234243695 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 W MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373034150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237451411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4234243695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3734665 | 05 | TN | MEDICAID | DF1630 | 01 | RR MEDICARE | OTHER |