Basic Information
| Provider Information | |||||||||
| NPI: | 1215932413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA MEDICAL GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | STE 301 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153275435 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N | ||||||||
| Address2: | STE 301 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153275435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | FORREST | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 6153274304 | ||||||||
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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 | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 7100516010 | 05 | KY | MEDICAID | 3372977 | 05 | TN | MEDICAID | 710051600 | 05 | KY | MEDICAID | 3604122 | 05 | TN | MEDICAID | 65910465 | 05 | KY | MEDICAID | 529402690 | 05 | AL | MEDICAID | 74903824 | 05 | KY | MEDICAID |