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NPI Code Detail

MEDICARE: BLUE WATER ANESTHESIA, LLC

MEDICARE: BLUE WATER ANESTHESIA, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse AnesthetistRN191954GA

General Provider Information

NPI Number : 1801291646
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLUE WATER ANESTHESIA, LLC
Provider Business Mailing Address
First Line : PO BOX 700
Second Line :
City : SNELLVILLE
State : GA
Zip : 30078-0700
Country : US
Telephone Number : 770-979-0900
Fax Number :
Provider Business Practice Location Address
First Line : 2175 NORTH RD
Second Line :
City : SNELLVILLE
State : GA
Zip : 30078-2630
Country : US
Telephone Number : 770-979-0900
Fax Number : 770-979-2852
Authorized Official
Title or Position : REGISTERED AGENT
Name : MR. BRUCE GAYNES
Credential :
Telephone Number : 404-467-7526
Provider Enumeration Date : 10/22/2014
Last Update Date : 01/26/2015

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Directions to “BLUE WATER ANESTHESIA, LLC ” Practice Location

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