Healthcare Provider Details

I. General information

NPI: 1669244406
Provider Name (Legal Business Name): DEEP RIVER ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT VINCENT CIR
LITTLE ROCK AR
72205-5423
US

IV. Provider business mailing address

1765 E NINE MILE RD STE 1-229
PENSACOLA FL
32514-5479
US

V. Phone/Fax

Practice location:
  • Phone: 501-552-3000
  • Fax:
Mailing address:
  • Phone: 410-429-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA BROWN
Title or Position: CFO
Credential:
Phone: 410-429-6115