Healthcare Provider Details

I. General information

NPI: 1568659670
Provider Name (Legal Business Name): PENN VALLEY ANESTHESIA ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 COOPER RD SUITE 100
VOORHEES NJ
08043-4910
US

IV. Provider business mailing address

1000 WHITE HORSE RD STE 612
VOORHEES NJ
08043-4412
US

V. Phone/Fax

Practice location:
  • Phone: 856-770-1950
  • Fax:
Mailing address:
  • Phone: 856-451-3552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT HAWK
Title or Position: AUTHORIZED OFFICIAL
Credential: CRNA
Phone: 856-451-3552