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General NPI Number Information
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NPI Number | 1902379928
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Entity Type | Organization
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Legal Business Name | FADE TO BLACK ANESTHESIA SERVICES
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Dates
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Enumeration Date | 01/03/2019
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Last Update Date | 01/03/2019
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Provider Practice Location Address
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Address Line | 7501 FORBES BLVD STE 103
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City | LANHAM
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State | MD
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Zip | 20706-6201
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Country | US
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Telephone | 215-500-7580
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 731
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City | LAUREL
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State | MD
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Zip | 20725-0731
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Country | US
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Telephone | 215-500-7580
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. RAJAEE BLACK
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Credential | CRNA
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Telephone | 215-500-7580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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