Basic Information
| Provider Information | |||||||||
| NPI: | 1629096490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AIKEN ANESTHESIOLOGY GROUP PA. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7397 | ||||||||
| Address2: | |||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298047397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 UNIVERSITY PKWY | ||||||||
| Address2: | AIKEN REGIONAL MEDICAL CENTER | ||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298016302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | ULMER | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3365531659 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CL5780 | 01 | SC | RRB | OTHER | GP0055 | 05 | SC | MEDICAID |