Healthcare Provider Details

I. General information

NPI: 1619149648
Provider Name (Legal Business Name): PROFESSIONAL ANESTHESIA GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DIXON ST STE 101
FREDERICKSBURG VA
22401-7231
US

IV. Provider business mailing address

PO BOX 222037
DALLAS TX
75222-2037
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-5349
  • Fax: 540-373-1745
Mailing address:
  • Phone: 239-610-0775
  • 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 Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: BRIAN P WOODS
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 214-687-0015