=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003443722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE LANIER ANESTHESIA ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2020
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2324 LIMESTONE OVERLOOK STE 200
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-7443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-257-5324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 737896
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75373-7896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-717-5383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP REV CYCLE
-----------------------------------------------------
Name | JEFF PERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-418-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------