Healthcare Provider Details

I. General information

NPI: 1578163770
Provider Name (Legal Business Name): SOUTHEAST ANESTHESIA, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PARK ST
BOWLING GREEN KY
42101-1742
US

IV. Provider business mailing address

PO BOX 293151
NASHVILLE TN
37229-3151
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-5111
  • Fax: 270-780-0478
Mailing address:
  • Phone: 615-620-2320
  • Fax: 615-620-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EDWARD MATTHEW DEMAREE
Title or Position: OWNER
Credential: CRNA
Phone: 615-865-5561