Provider Demographics
NPI:1275504771
Name:ALTA ANESTHESIA ASSOCIATES OF GEORGIA, PC
Entity Type:Organization
Organization Name:ALTA ANESTHESIA ASSOCIATES OF GEORGIA, PC
Other - Org Name:SOUTHEAST GEORGIA REGIONAL
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICH
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-264-0014
Mailing Address - Street 1:4 SAINT ANDREWS CT
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-6764
Mailing Address - Country:US
Mailing Address - Phone:912-264-0014
Mailing Address - Fax:912-264-5003
Practice Address - Street 1:3100 KEMBLE AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4211
Practice Address - Country:US
Practice Address - Phone:912-264-0014
Practice Address - Fax:912-264-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207L00000X, 363A00000X, 367500000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2770Medicare PIN