1467497081 NPI number — PIEDMONT TRIAD ANESTHESIA, PA

Table of content: (NPI 1467497081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467497081 NPI number — PIEDMONT TRIAD ANESTHESIA, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIEDMONT TRIAD ANESTHESIA, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467497081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
145 KIMEL PARK DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-6983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-768-3212
Provider Business Mailing Address Fax Number:
336-768-9019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 KIMEL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
WINSTON-SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-6983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-768-3212
Provider Business Practice Location Address Fax Number:
336-768-9019
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUKISH
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
336-768-3212

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 016HA . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DC6484 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8000325 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89016HA , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017035100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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