Basic Information
| Provider Information | |||||||||
| NPI: | 1679585970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALLADEGA ANESTHESIOLOGY GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660685 | ||||||||
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| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352660685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 STONE AVE | ||||||||
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| City: | TALLADEGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351602217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563628111 | ||||||||
| FaxNumber: | 2567614203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | SUZANE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2567614047 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CN5627 | 01 | AL | RR MEDICARE GROUP # | OTHER | 529801440 | 05 | AL | MEDICAID |