Healthcare Provider Details

I. General information

NPI: 1750867297
Provider Name (Legal Business Name): MIDLANDS ANESTHESIOLOGISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

PO BOX 16656
ATLANTA GA
30321-0656
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-2394
  • Fax:
Mailing address:
  • Phone: 803-765-1838
  • Fax: 803-765-1732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LESLIE S LONG
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 803-254-2394