Healthcare Provider Details

I. General information

NPI: 1558728907
Provider Name (Legal Business Name): FIRST SOURCE ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 MULBERRY ST STE 110
MACON GA
31201-8220
US

IV. Provider business mailing address

PO BOX 850001 DEPT #249
ORLANDA FL
32885-0249
US

V. Phone/Fax

Practice location:
  • Phone: 888-728-0882
  • Fax:
Mailing address:
  • Phone: 888-728-0882
  • Fax: 888-512-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RICHARD DOUBERLY
Title or Position: MEMBER MANAGER
Credential: CRNA
Phone: 888-728-0882