Healthcare Provider Details

I. General information

NPI: 1124415567
Provider Name (Legal Business Name): NORTHSTAR ANESTHESIA OF MISSISSIPPI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 SERGEANT PRENTISS DR
NATCHEZ MS
39120-4726
US

IV. Provider business mailing address

PO BOX 610506
DALLAS TX
75261-0506
US

V. Phone/Fax

Practice location:
  • Phone: 601-443-2100
  • Fax:
Mailing address:
  • Phone: 239-610-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA LUMBLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 214-687-0001