Basic Information
| Provider Information | |||||||||
| NPI: | 1275859787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARKSVILLE ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4860 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436512624 | ||||||||
| FaxNumber: | 8433574940 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370435000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315520180 | ||||||||
| FaxNumber: | 9315720915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8436512624 | ||||||||
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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 | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.