Healthcare Provider Details

I. General information

NPI: 1154595031
Provider Name (Legal Business Name): PREMIER ANESTHESIA OF FAIRMONT, WV, A DIVISION OF PREMIER ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LOCUST AVE
FAIRMONT WV
26554-1435
US

IV. Provider business mailing address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-7100
  • Fax:
Mailing address:
  • Phone: 678-277-3055
  • 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 Code207LC0200X
TaxonomyCritical Care 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: NORBERT D HUMMEL III
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 877-742-0399