Healthcare Provider Details

I. General information

NPI: 1023779691
Provider Name (Legal Business Name): PROVIDENCE ANESTHESIOLOGY ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 GLENLAKE DR STE 250
CHARLOTTE NC
28208-6866
US

IV. Provider business mailing address

3735 GLENLAKE DR STE 250
CHARLOTTE NC
28208-6866
US

V. Phone/Fax

Practice location:
  • Phone: 704-749-5800
  • Fax: 704-626-3272
Mailing address:
  • Phone: 704-749-5800
  • Fax: 704-626-3272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LORI A HELMICK
Title or Position: DIRECTOR, PROVIDER RELATIONS
Credential:
Phone: 704-749-5800