Basic Information
| Provider Information | |||||||||
| NPI: | 1225086069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESMARK SURGERY CENTER ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436512624 | ||||||||
| FaxNumber: | 8433574940 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W WESMARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291501983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039055590 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROYAL | ||||||||
| AuthorizedOfficialFirstName: | PATSY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8039055590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | GP4179 | 05 | SC | MEDICAID |