Basic Information
| Provider Information | |||||||||
| NPI: | 1720076474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATION OF HOSPITAL ANESTHESIOLOGISTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SCOTT NIXON MEMORIAL DR | ||||||||
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| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309072464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066500705 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 2ND ST | ||||||||
| Address2: | STE. A107 | ||||||||
| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549562883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207293332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 09/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | ORTH | ||||||||
| AuthorizedOfficialFirstName: | KARL | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD OF GROUP | ||||||||
| AuthorizedOfficialTelephone: | 9207293332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| 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 | 21267300 | 05 | WI | MEDICAID |