Healthcare Provider Details

I. General information

NPI: 1093153538
Provider Name (Legal Business Name): SUWANEE ANESTHESIA SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3858 SHADOW LOCH DR
SUWANEE GA
30024-7003
US

IV. Provider business mailing address

PO BOX 629
PERRY GA
31069-0629
US

V. Phone/Fax

Practice location:
  • Phone: 478-929-0036
  • Fax: 478-929-1744
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN054969
License Number StateGA

VIII. Authorized Official

Name: ROBERT WOOD
Title or Position: CEO/PRESIDENT
Credential: CRNA
Phone: 478-929-0036