Basic Information
| Provider Information | |||||||||
| NPI: | 1720467392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIERE ANESTHESIA GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5127 HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295765045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436512624 | ||||||||
| FaxNumber: | 8434914023 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 S LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600684506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472080353 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHAUFF | ||||||||
| AuthorizedOfficialFirstName: | BERTRAND | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8472080353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209010019 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.