MEDICARE: LOOKAWAY ANESTHESIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	367500000X	Certified Registered Nurse Anesthetist
2	367H00000X	Anesthesiologist Assistant
3	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1043764814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOOKAWAY ANESTHESIA LLC

Provider Business Mailing Address
First Line	:	PO BOX 681
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29202-0681
Country	:	US
Telephone Number	:	803-765-1838
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 SURGEONS DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-5198
Country	:	US
Telephone Number	:	843-504-7194
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RYAN SMITH
Credential	:	MD
Telephone Number	:	843-504-7194

Provider Enumeration Date	:	08/10/2016
Last Update Date	:	08/29/2016

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Directions to “LOOKAWAY ANESTHESIA LLC ” Practice Location

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