Basic Information
| Provider Information | |||||||||
| NPI: | 1144220245 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTE COMMUNITY ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7836 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300651836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782022060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1984 PEACHTREE RD NW | ||||||||
| Address2: | SUITE 515 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOLESAR | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4043511745 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.