Provider Demographics
NPI:1194381236
Name:RADIANCE ANESTHESIA
Entity Type:Organization
Organization Name:RADIANCE ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOUBERLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:941-360-1566
Mailing Address - Street 1:PO BOX 850001 DEPT 740J
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-0740
Mailing Address - Country:US
Mailing Address - Phone:240-469-2179
Mailing Address - Fax:
Practice Address - Street 1:577 MULBERRY ST STE 110
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8220
Practice Address - Country:US
Practice Address - Phone:240-469-2179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty