Healthcare Provider Details

I. General information

NPI: 1700180122
Provider Name (Legal Business Name): MERIDIAN ANESTHESIA CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

770 PINE STREET SUITE L40
MACON GA
31201
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1000
  • Fax: 478-742-9670
Mailing address:
  • Phone: 478-742-8297
  • Fax: 478-742-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number99999
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number99999
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number99999
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number99999
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number99999
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number999999
License Number StateGA

VIII. Authorized Official

Name: ARTHUR RICHARD GRAY JR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 478-742-8297