=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144760760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MJM ANESTHESIA ,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2017
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7945 MACARTHUR BLVD # 101-235
-----------------------------------------------------
City | CABIN JOHN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20818-0235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-964-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7945 MACARTHUR BLVD #101-235
-----------------------------------------------------
City | CABIN JOHN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20818-0235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-964-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HEATHER DAILEY
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 202-964-1160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | R147286
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------