Healthcare Provider Details

I. General information

NPI: 1679933774
Provider Name (Legal Business Name): EXCALIBUR ANESTHESIA ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SIGMAN RD NE SUITE 120
CONYERS GA
30012-3812
US

IV. Provider business mailing address

PO BOX 776
CONYERS GA
30012-0776
US

V. Phone/Fax

Practice location:
  • Phone: 770-760-9360
  • Fax:
Mailing address:
  • Phone:
  • 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: ROY L TALLEY JR.
Title or Position: OWNER
Credential: MD
Phone: 770-760-9360