=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447202452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE VALLEY ANESTHESIA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 N MEADOWS DR
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-649-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5483 W WATERS AVE STE 1200
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33634-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-287-5718
-----------------------------------------------------
Fax | 813-287-5728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MANAGER
-----------------------------------------------------
Name | MR. MICHAEL J FAHEY
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 423-618-3448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------