Provider Demographics
NPI:1255482550
Name:MONROE ANESTHESIA SERVICES
Entity Type:Organization
Organization Name:MONROE ANESTHESIA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRISON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUITTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-929-5858
Mailing Address - Street 1:PO BOX 724928
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-9028
Mailing Address - Country:US
Mailing Address - Phone:770-929-5858
Mailing Address - Fax:
Practice Address - Street 1:316 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2150
Practice Address - Country:US
Practice Address - Phone:770-929-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7961OtherMEDICARE GROUP NUMBER
GAGRP7961OtherMEDICARE GROUP NUMBER
GA05BDLMZMedicare PIN
GA43BBDCSMedicare PIN