Healthcare Provider Details

I. General information

NPI: 1073632600
Provider Name (Legal Business Name): PREMIER ANESTHESIA ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 ALCOVY ST
MONROE GA
30655-2140
US

IV. Provider business mailing address

PO BOX 724928
ATLANTA GA
31139-9028
US

V. Phone/Fax

Practice location:
  • Phone: 678-838-1585
  • Fax:
Mailing address:
  • Phone: 678-838-1585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: TINA RIGDON
Title or Position: BILLING SERVICE
Credential:
Phone: 678-838-1585