Basic Information
| Provider Information | |||||||||
| NPI: | 1679544183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRENADA ANESTHESIOLOGY INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235019 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342791450 | ||||||||
| FaxNumber: | 3343954110 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 AVENT DR | ||||||||
| Address2: | |||||||||
| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389015230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622277336 | ||||||||
| FaxNumber: | 6622277000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 07/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6622277336 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 512G700493 | 01 | MS | MEDICARE GROUP # | OTHER |