Provider Demographics
NPI:1275996787
Name:MAK ANESTHESIA DIRECT SERVICES LLC
Entity Type:Organization
Organization Name:MAK ANESTHESIA DIRECT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIGANDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-702-1806
Mailing Address - Street 1:1635 OLD 41 HWY NW
Mailing Address - Street 2:SUITE 112-328
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4480
Mailing Address - Country:US
Mailing Address - Phone:770-702-1806
Mailing Address - Fax:
Practice Address - Street 1:11681 HAYNES BRIDGE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2133
Practice Address - Country:US
Practice Address - Phone:770-702-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAK ANESTHESIA PROVIDERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051609207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty