Basic Information
| Provider Information | |||||||||
| NPI: | 1669475190 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOTAL ANESTHESIA CARE STPH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 INNWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704339123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858923225 | ||||||||
| FaxNumber: | 9852340628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 S TYLER ST | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704332330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858984000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2005 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANDRA DIPIETRO | ||||||||
| AuthorizedOfficialFirstName: | SHAN MCDANIEL | ||||||||
| AuthorizedOfficialMiddleName: | AND | ||||||||
| AuthorizedOfficialTitleorPosition: | COO & CFO | ||||||||
| AuthorizedOfficialTelephone: | 9858923225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
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 | 1441759 | 05 | LA | MEDICAID | 09016177 | 05 | MS | MEDICAID |