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General NPI Number Information
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NPI Number | 1366845554
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Entity Type | Organization
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Legal Business Name | MISSISSIPPI ANESTHESIA GROUP, LLC
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Dates
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Enumeration Date | 10/01/2014
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Last Update Date | 10/01/2014
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Provider Practice Location Address
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Address Line | 145 SANCTUARY LN
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City | CANTON
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State | MS
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Zip | 39046-6601
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Country | US
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Telephone | 601-855-7440
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Fax |
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Provider Business Mailing Address
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Address Line | 2714 W OXFORD LOOP STE 161
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City | OXFORD
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State | MS
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Zip | 38655-5711
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Country | US
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Telephone | 662-550-4299
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Fax | 662-580-4324
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Authorized Official
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Title or Position | FOUNDER AND PRESIDENT
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Name | GARY DWAYNE SELF
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Credential | CRNA
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Telephone | 601-668-5628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | R598755
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License Number State | MS
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