=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407390792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY ANESTHESIA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2016
-----------------------------------------------------
Last Update Date | 03/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 695 S BENNETT ST
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-687-6187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 695 S BENNETT ST
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-687-6187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JAMES EDWARD TAYLOR II
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 910-687-6187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 156084
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------