Basic Information
Provider Information | |||||||||
NPI: | 1629068416 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEVIER ANESTHESIA ASSOCIATES, P.C | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 E 10TH ST | ||||||||
Address2: |   | ||||||||
City: | WACONIA | ||||||||
State: | MN | ||||||||
PostalCode: | 553874552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524429770 | ||||||||
FaxNumber: | 9524423630 | ||||||||
Practice Location | |||||||||
Address1: | 709 MIDDLE CREEK RD | ||||||||
Address2: |   | ||||||||
City: | SEVIERVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378625047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8654296609 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2005 | ||||||||
LastUpdateDate: | 08/22/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLS | ||||||||
AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
AuthorizedOfficialMiddleName: | JEFF | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 9524429770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CRNA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | TN0100 | 01 | TN | BLUE CROSS OF TENNESSEE | OTHER | 3620339 | 05 | TN |   | MEDICAID |