Healthcare Provider Details

I. General information

NPI: 1578656948
Provider Name (Legal Business Name): CHARLESTON ANESTHESIA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HENRY TECKLENBURG DR
CHARLESTON SC
29414-5733
US

IV. Provider business mailing address

PO BOX 93
LANDISVILLE PA
17538-0093
US

V. Phone/Fax

Practice location:
  • Phone: 843-402-1000
  • Fax:
Mailing address:
  • Phone: 800-800-1617
  • Fax: 866-759-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ALAN DALE HILLIARD
Title or Position: CFO
Credential:
Phone: 336-884-1830