Basic Information
| Provider Information | |||||||||
| NPI: | 1780060079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSYNERGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52404 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705052404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068602701 | ||||||||
| FaxNumber: | 7068606484 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 LONGWOOD DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564697895 | ||||||||
| FaxNumber: | 2562708937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | KILLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2564697895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 99999 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 367500000X | 99999 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367H00000X | 99999 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 207L00000X | 999999 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.