Basic Information
| Provider Information | |||||||||
| NPI: | 1619265550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENNESSEE ANESTHESIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926100 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233920344 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | LLOYD | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 4233926100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
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 | 4306528 | 01 | TN | BCBSTN | OTHER | 1525088 | 05 | TN | MEDICAID |