Healthcare Provider Details

I. General information

NPI: 1083484000
Provider Name (Legal Business Name): IVORY COAST ANESTHESIA MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 9TH ST
JASPER IN
47546-2514
US

IV. Provider business mailing address

PO BOX 830560
PHILADELPHIA PA
19182-0560
US

V. Phone/Fax

Practice location:
  • Phone: 850-985-9180
  • Fax:
Mailing address:
  • Phone:
  • 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: MARGARITE GARNER
Title or Position: VICE PRESIDENT OPERATIONS
Credential:
Phone: 904-298-9590