=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700180122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERIDIAN ANESTHESIA CONSULTANTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2010
-----------------------------------------------------
Last Update Date | 04/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 HEMLOCK ST
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31201-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-633-1000
-----------------------------------------------------
Fax | 478-742-9670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 770 PINE STREET SUITE L40
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-742-8297
-----------------------------------------------------
Fax | 478-742-9670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | ARTHUR RICHARD GRAY JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 478-742-8297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 999999
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------