Healthcare Provider Details

I. General information

NPI: 1700287232
Provider Name (Legal Business Name): SIESTA ANESTHESIA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HARTSFIELD CENTER PKWY SUITE 500
ATLANTA GA
30354-1341
US

IV. Provider business mailing address

100 HARTSFIELD CENTER PKWY SUITE 500
ATLANTA GA
30354-1341
US

V. Phone/Fax

Practice location:
  • Phone: 404-376-3639
  • Fax:
Mailing address:
  • Phone: 404-376-3639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TAJ K. EUBANKS
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 404-376-3639