Healthcare Provider Details

I. General information

NPI: 1811403207
Provider Name (Legal Business Name): PREMIER ANESTHESIA OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UPPER RIVERDALE RD
RIVERDALE GA
30274
US

IV. Provider business mailing address

500 NORTHRIDGE RD STE 330
ATLANTA GA
30350-3314
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-8000
  • Fax: 404-941-1264
Mailing address:
  • Phone: 404-941-1291
  • Fax: 404-941-1264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD POSEY
Title or Position: VICE PRESIDENT OF REVENUE CYCLE
Credential:
Phone: 404-941-1261