Healthcare Provider Details

I. General information

NPI: 1841760238
Provider Name (Legal Business Name): MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 HENDERSONVILLE RD STE 206
ARDEN NC
28704-8576
US

IV. Provider business mailing address

PO BOX 603366
CHARLOTTE NC
28260-3366
US

V. Phone/Fax

Practice location:
  • Phone: 828-213-1740
  • Fax:
Mailing address:
  • Phone: 828-213-1500
  • Fax: 828-681-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARILYN TATHAM
Title or Position: PROVIDER ENROLLMENT MANAGER
Credential: DO
Phone: 828-651-6595