Healthcare Provider Details

I. General information

NPI: 1609914373
Provider Name (Legal Business Name): SOUTHWEST MISSISSIPPI ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E AIRPORT AVE
BATON ROUGE LA
70806-6515
US

IV. Provider business mailing address

505 E AIRPORT AVE
BATON ROUGE LA
70806-6515
US

V. Phone/Fax

Practice location:
  • Phone: 225-201-0950
  • Fax: 225-923-3488
Mailing address:
  • Phone: 225-201-0950
  • Fax: 225-923-3488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BETH H BROADWAY
Title or Position: ADMINISTRATOR
Credential:
Phone: 225-201-0950