Basic Information
| Provider Information | |||||||||
| NPI: | 1861004715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOLSOM ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69323 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212649323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413601566 | ||||||||
| FaxNumber: | 9413589818 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057537111 | ||||||||
| FaxNumber: | 5057534438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2020 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZUMWALT | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9413601566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.