=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144549825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A&W ANESTHESIA SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2010
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5530 WISCONSIN AVE SUITE 1550
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20815-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-727-1352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 71155
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20813-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-727-1352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | REZA GHORBANI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 781-727-1352
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------