Healthcare Provider Details

I. General information

NPI: 1518231554
Provider Name (Legal Business Name): GATEWAY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 HARLOW RD SUITE 110
SPRINGFIELD OR
97477-7124
US

IV. Provider business mailing address

PO BOX 4860
MURRELLS INLET SC
29576-2698
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-8882
  • Fax: 541-726-8844
Mailing address:
  • Phone: 843-651-2624
  • Fax: 843-357-4940

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: MICHAEL T. MITCHELL
Title or Position: BUSINESS MANAGER
Credential:
Phone: 843-651-2624