Healthcare Provider Details

I. General information

NPI: 1144690033
Provider Name (Legal Business Name): RIVERSIDE ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2258 WRIGHTSBORO RD
AUGUSTA GA
30904-4887
US

IV. Provider business mailing address

647 DEERWOOD WAY
EVANS GA
30809-4401
US

V. Phone/Fax

Practice location:
  • Phone: 706-737-8827
  • Fax:
Mailing address:
  • Phone: 706-533-4609
  • Fax: 706-364-6593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARTIN TAYLOR
Title or Position: OWNER
Credential: CRNA
Phone: 706-533-4609