Provider Demographics
NPI:1487654455
Name:ANESTHESIA MEDICAL GROUP
Entity Type:Organization
Organization Name:ANESTHESIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:304-925-5486
Mailing Address - Street 1:3508 STAUNTON AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1477
Mailing Address - Country:US
Mailing Address - Phone:304-925-5486
Mailing Address - Fax:304-925-8075
Practice Address - Street 1:3508 STAUNTON AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1477
Practice Address - Country:US
Practice Address - Phone:304-925-5486
Practice Address - Fax:304-925-8075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0063882001Medicaid
WV0063882001Medicaid