Provider Demographics
NPI:1144220245
Name:FAYETTE COMMUNITY ANESTHESIA
Entity Type:Organization
Organization Name:FAYETTE COMMUNITY ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLESAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-351-1745
Mailing Address - Street 1:PO BOX 7836
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30065-1836
Mailing Address - Country:US
Mailing Address - Phone:678-202-2060
Mailing Address - Fax:
Practice Address - Street 1:1984 PEACHTREE RD NW
Practice Address - Street 2:SUITE 515
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1298
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3017Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER