=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982658019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEERCREEK ANESTHESIA CONSULTANTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1307 WEST AVE SUITE 102
-----------------------------------------------------
City | CROSSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38555-5107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-456-4433
-----------------------------------------------------
Fax | 931-456-4405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1307 WEST AVE SUITE 102
-----------------------------------------------------
City | CROSSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38555-5107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-456-4433
-----------------------------------------------------
Fax | 931-456-4405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO PRESIDENT
-----------------------------------------------------
Name | THOMAS LASALLE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 931-456-4433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------