Provider Demographics
NPI:1508336157
Name:MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Entity Type:Organization
Organization Name:MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Other - Org Name:PEDIATRIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-651-6595
Mailing Address - Street 1:PO BOX 603366
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:828-681-1575
Practice Address - Street 1:11 VANDERBILT PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803
Practice Address - Country:US
Practice Address - Phone:828-213-1740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-27
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02CG9OtherBC/BS OF NC
NC027N4OtherBC/BS OF NC