Healthcare Provider Details

I. General information

NPI: 1467927038
Provider Name (Legal Business Name): GLGA ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 JESSE JEWELL PKWY SE STE 100
GAINESVILLE GA
30501-3871
US

IV. Provider business mailing address

1090 EXPERIMENT STATION RD UNIT 529
WATKINSVILLE GA
30677-5378
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-7277
  • Fax: 678-450-3761
Mailing address:
  • Phone: 706-623-6699
  • Fax: 706-850-7733

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: JEFFREY NICKELL
Title or Position: CFO
Credential:
Phone: 706-623-6699