Basic Information
| Provider Information | |||||||||
| NPI: | 1720059249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA REGIONAL ANESTHESIOLOGY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235019 | ||||||||
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| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002325703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 E UNION ST | ||||||||
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| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387033246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623342005 | ||||||||
| FaxNumber: | 6623342189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOWLIN | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN RECRUITMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6623342005 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DELTA REGIONAL HOSPITAL | ||||||||
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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 | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.