1366858185 NPI number — ENTI ANESTHESIA, LLC

Table of content: GRACE LEE PARK M.D. (NPI 1619147592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366858185 NPI number — ENTI ANESTHESIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENTI ANESTHESIA, LLC
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:
1366858185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2365 OLD MILTON PKWY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30009-2140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-740-1860
Provider Business Mailing Address Fax Number:
678-347-2104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1595 HIGHWAY 34 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-2353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-206-2202
Provider Business Practice Location Address Fax Number:
678-673-5155
Provider Enumeration Date:
07/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GALLUPS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-740-1860

Provider Taxonomy Codes

  • Taxonomy code: 207YS0123X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14063148 . This is a "CERTIFICATE OF ORGANIZATION" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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