Basic Information
| Provider Information | |||||||||
| NPI: | 1972743987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLATINUM ANESTHESIA COASTAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | TENNILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310890068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006059961 | ||||||||
| FaxNumber: | 8007820704 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N RIVER ST | ||||||||
| Address2: | DEPT OF ANESTHESIA | ||||||||
| City: | CLAXTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304171659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127395000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2009 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | ATKINSON | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8006059961 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 568167122A | 05 | GA | MEDICAID | DO7086 | 01 | GA | MEDICARE RAILROAD | OTHER |