=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114927738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN ANESTHESIOLOGY GROUP OF TENNESSEE, P. C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2005
-----------------------------------------------------
Last Update Date | 12/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 W RAVINE RD STE 5-B
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37660-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-224-3460
-----------------------------------------------------
Fax | 423-224-3465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 W RAVINE RD STE 5-B
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37660-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-224-3460
-----------------------------------------------------
Fax | 423-224-3465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | FRANCIS ABDOU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 423-224-3460
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------