Healthcare Provider Details

I. General information

NPI: 1649260738
Provider Name (Legal Business Name): ADVANCED ANESTHESIA ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

405 ARROWHEAD BLVD SUITE C
JONESBORO GA
30236-1254
US

V. Phone/Fax

Practice location:
  • Phone: 770-478-9877
  • Fax: 770-478-2908
Mailing address:
  • Phone: 770-478-9877
  • Fax: 770-478-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number207L00000X
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number208VP0000X
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number367500000X
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number367H00000X
License Number StateGA

VIII. Authorized Official

Name: MR. DANIEL H. WORLEY
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 770-478-9877