Healthcare Provider Details

I. General information

NPI: 1003069527
Provider Name (Legal Business Name): TAILORED ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 HUNT CLUB DR
COROLLA NC
27927-9573
US

IV. Provider business mailing address

670 HUNT CLUB DR
COROLLA NC
27927-9573
US

V. Phone/Fax

Practice location:
  • Phone: 252-453-3118
  • Fax: 252-597-1884
Mailing address:
  • Phone: 252-453-3118
  • Fax: 252-597-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR096528
License Number StateMD

VIII. Authorized Official

Name: MR. GREGORY G TAYLOR
Title or Position: CEO
Credential: CRNA
Phone: 301-538-5352