Provider Demographics
NPI:1386028744
Name:MAK ANESTHESIA, LLC
Entity Type:Organization
Organization Name:MAK ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
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 STE 112-328
Mailing Address - Street 2:
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 1:1621 N ROBERTS RD NW STE 110
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3640
Practice Address - Country:US
Practice Address - Phone:770-702-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOCC003663207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty