Basic Information
| Provider Information | |||||||||
| NPI: | 1821369448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAK ANESTHESIA EWSC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 OLD 41 HIGHWAY NW, SUITE 112-328 | ||||||||
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| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707021806 | ||||||||
| FaxNumber: | 7706930810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 MESA VALLEY WAY | ||||||||
| Address2: | STE 125 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783098100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2012 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | WEIGANDT | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7707021806 | ||||||||
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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 |
No ID Information.