Basic Information
| Provider Information | |||||||||
| NPI: | 1952934655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THOMASVILLE REGIONAL MEDICAL ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THOMASVILLE REGIONAL ANESTHESIA GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660257 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352660257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MED PARK DR | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367845760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346362525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2020 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRICKNER | ||||||||
| AuthorizedOfficialFirstName: | BREANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2059032392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.