Provider Demographics
NPI:1467497081
Name:PIEDMONT TRIAD ANESTHESIA, PA
Entity Type:Organization
Organization Name:PIEDMONT TRIAD ANESTHESIA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKISH
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:336-768-3212
Mailing Address - Street 1:145 KIMEL PARK DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6983
Mailing Address - Country:US
Mailing Address - Phone:336-768-3212
Mailing Address - Fax:336-768-9019
Practice Address - Street 1:145 KIMEL PARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6983
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016HAOtherBCBS
NCDC6484OtherRR MEDICARE
NC8000325Medicaid
NC89016HAMedicaid
NC2339461Medicare ID - Type UnspecifiedPHYSICIAN GROUP PROV #
NC89016HAMedicaid