Provider Demographics
NPI:1003069527
Name:TAILORED ANESTHESIA SERVICES LLC
Entity Type:Organization
Organization Name:TAILORED ANESTHESIA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:G
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:301-538-5352
Mailing Address - Street 1:670 HUNT CLUB DR
Mailing Address - Street 2:
Mailing Address - City:COROLLA
Mailing Address - State:NC
Mailing Address - Zip Code:27927-9573
Mailing Address - Country:US
Mailing Address - Phone:252-453-3118
Mailing Address - Fax:252-597-1884
Practice Address - Street 1:670 HUNT CLUB DR
Practice Address - Street 2:
Practice Address - City:COROLLA
Practice Address - State:NC
Practice Address - Zip Code:27927-9573
Practice Address - Country:US
Practice Address - Phone:252-453-3118
Practice Address - Fax:252-597-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR096528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC135602Medicare PIN
MD138299Medicare PIN