Healthcare Provider Details

I. General information

NPI: 1063880052
Provider Name (Legal Business Name): ALLIANCE ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 S SAGINAW ST
FLINT MI
48507-2677
US

IV. Provider business mailing address

4800 S SAGINAW ST STE 1845
FLINT MI
48507-2677
US

V. Phone/Fax

Practice location:
  • Phone: 810-732-8336
  • Fax: 810-239-4346
Mailing address:
  • Phone: 810-732-8336
  • Fax: 810-239-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704215191
License Number StateMI

VIII. Authorized Official

Name: ATIF BAWAHAB
Title or Position: ADMIN
Credential:
Phone: 979-574-7109