Healthcare Provider Details

I. General information

NPI: 1548508872
Provider Name (Legal Business Name): AMSURG WILLOUGHBY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34940 RIDGE RD
WILLOUGHBY OH
44094-4196
US

IV. Provider business mailing address

1A BURTON HILLS BLVD ATTN: PROVIDER ENROLLMENT
NASHVILLE TN
37215-6187
US

V. Phone/Fax

Practice location:
  • Phone: 440-953-4429
  • Fax:
Mailing address:
  • Phone: 615-240-3809
  • Fax: 615-234-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PHILLIP A. CLENDENIN
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283