Provider Demographics
NPI:1356449573
Name:PREMIER ANESTHESIA GROUP
Entity Type:Organization
Organization Name:PREMIER ANESTHESIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MAHOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-257-8460
Mailing Address - Street 1:51 WISPY WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6432
Mailing Address - Country:US
Mailing Address - Phone:919-498-2125
Mailing Address - Fax:
Practice Address - Street 1:525 SAMARITANS RIDGE CT
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2457
Practice Address - Country:US
Practice Address - Phone:336-835-5330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center