Healthcare Provider Details

I. General information

NPI: 1275504771
Provider Name (Legal Business Name): ALTA ANESTHESIA ASSOCIATES OF GEORGIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 KEMBLE AVE
BRUNSWICK GA
31520-4211
US

IV. Provider business mailing address

4 SAINT ANDREWS CT
BRUNSWICK GA
31520-6764
US

V. Phone/Fax

Practice location:
  • Phone: 912-264-0014
  • Fax: 912-264-5003
Mailing address:
  • Phone: 912-264-0014
  • Fax: 912-264-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: RICH OTT
Title or Position: ADMINISTRATOR/MANAGER
Credential:
Phone: 912-264-0014