Healthcare Provider Details

I. General information

NPI: 1144588955
Provider Name (Legal Business Name): PHYSICIAN'S ANESTHESIA SERVICES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 BILL GARDNER PKWY
LOCUST GROVE GA
30248-3644
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-0100
  • Fax: 843-357-4940
Mailing address:
  • Phone: 714-347-1010
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number12003075
License Number StateGA

VIII. Authorized Official

Name: MRS. ARUNA R. PRAKASH
Title or Position: ADMINISTRATOR
Credential: B.SC
Phone: 770-692-0100