Healthcare Provider Details

I. General information

NPI: 1043309271
Provider Name (Legal Business Name): CARDIAC ANESTHESIA GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W FOREST AVE
JACKSON TN
38301-3942
US

IV. Provider business mailing address

PO BOX 3572
JACKSON TN
38303-3572
US

V. Phone/Fax

Practice location:
  • Phone: 731-668-1853
  • Fax:
Mailing address:
  • Phone: 731-668-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: MS. PATTI BARNES
Title or Position: OFFICE MANAGER
Credential:
Phone: 731-668-1853