Provider Demographics
NPI:1225404809
Name:TAILORED ANESTHESIA SERVICES LLC
Entity Type:Organization
Organization Name:TAILORED ANESTHESIA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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 1:3810 WATERSIDE DR APT 104
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9739
Mailing Address - Country:US
Mailing Address - Phone:301-538-5352
Mailing Address - Fax:252-621-1003
Practice Address - Street 1:3810 WATERSIDE DR APT 104
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9739
Practice Address - Country:US
Practice Address - Phone:301-538-5352
Practice Address - Fax:252-621-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC158154367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC15202003000152OtherDCN
NCQ45087E830OtherPROVIDER PTAN