Basic Information
Provider Information | |||||||||
NPI: | 1164748935 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEAST GEORGIA ANESTHESIOLOGY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 310 | ||||||||
Address2: |   | ||||||||
City: | WATKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 306770008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8883373509 | ||||||||
FaxNumber: | 9413283997 | ||||||||
Practice Location | |||||||||
Address1: | 3320 OLD JEFFERSON RD | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | GA | ||||||||
PostalCode: | 306071400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7066234271 | ||||||||
FaxNumber: | 7062257217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2010 | ||||||||
LastUpdateDate: | 03/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEIR | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
AuthorizedOfficialTelephone: | 7064252239 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.