1972743987 NPI number — PLATINUM ANESTHESIA COASTAL, 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 1972743987 NPI number — PLATINUM ANESTHESIA COASTAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLATINUM ANESTHESIA COASTAL, 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:
1972743987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 68
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TENNILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31089-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-605-9961
Provider Business Mailing Address Fax Number:
800-782-0704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 N RIVER ST
Provider Second Line Business Practice Location Address:
DEPT OF ANESTHESIA
Provider Business Practice Location Address City Name:
CLAXTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30417-1659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-739-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ATKINSON
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
800-605-9961

Provider Taxonomy Codes

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

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

  • Identifier: 568167122A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DO7086 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".