Healthcare Provider Details

I. General information

NPI: 1043764814
Provider Name (Legal Business Name): LOOKAWAY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SURGEONS DR
MYRTLE BEACH SC
29579-5198
US

IV. Provider business mailing address

PO BOX 681
COLUMBIA SC
29202-0681
US

V. Phone/Fax

Practice location:
  • Phone: 843-504-7194
  • Fax:
Mailing address:
  • Phone: 803-765-1838
  • 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
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name: RYAN SMITH
Title or Position: OWNER
Credential: MD
Phone: 843-504-7194