=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174670103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BDT ANESTHESIA ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 09/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2260 WRIGHTSBORO RD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-4764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-481-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3330
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30914-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-278-2473
-----------------------------------------------------
Fax | 803-278-2473
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | DR. DONALD B TALLEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 803-278-2473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 31336
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------