1548696925 NPI number — GULF ANESTHESIA SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548696925 NPI number — GULF ANESTHESIA SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF ANESTHESIA SERVICES 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:
1548696925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24023
Provider Second Line Business Mailing Address:
DEPT 03-084
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-4023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-860-0820
Provider Business Mailing Address Fax Number:
228-731-3446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12504 WINDANCE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503-7780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-860-0820
Provider Business Practice Location Address Fax Number:
228-731-3446
Provider Enumeration Date:
09/17/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BENEFIELD
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
BLAKE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
228-860-0820

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R863937 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: R867945 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: R874062 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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