Healthcare Provider Details

I. General information

NPI: 1497726160
Provider Name (Legal Business Name): CARDIOVASCULAR ANSTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 FOREST DR
COLUMBIA SC
29204-2026
US

IV. Provider business mailing address

PO BOX 25448
COLUMBIA SC
29224-5448
US

V. Phone/Fax

Practice location:
  • Phone: 803-765-1838
  • Fax: 803-765-1732
Mailing address:
  • Phone: 803-765-1838
  • Fax: 803-765-1732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN F WILLIAMS
Title or Position: PRESIDENT
Credential:
Phone: 803-256-0447