1639181019 NPI number — MERIDIAN ANESTHESIOLOGY GROUP, INC

Table of content: (NPI 1639181019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639181019 NPI number — MERIDIAN ANESTHESIOLOGY GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN ANESTHESIOLOGY GROUP, INC
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:
1639181019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 16TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39301-4209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-485-6325
Provider Business Mailing Address Fax Number:
601-485-3061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 16TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-4209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-485-6325
Provider Business Practice Location Address Fax Number:
601-485-3061
Provider Enumeration Date:
08/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
DON
Authorized Official Middle Name:
LARKIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-703-9614

Provider Taxonomy Codes

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

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

  • Identifier: CB3237 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 09015692 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".