Basic Information
| Provider Information | |||||||||
| NPI: | 1396739884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE ANESTHESIOLOGY ASSOCIATES, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRESBYTERIAN ANESTHESIA ASSOCIATES P.A, | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3735 GLENLAKE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282086866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047495800 | ||||||||
| FaxNumber: | 7046263272 | ||||||||
| Practice Location | |||||||||
| Address1: | 3735 GLENLAKE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282086866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047495800 | ||||||||
| FaxNumber: | 7046263272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2005 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | DUCEY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7047495800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 890180H | 05 | NC | MEDICAID |