Provider Demographics
NPI:1568571743
Name:PROFESSIONAL ANESTHESIA ASSOCIATES
Entity Type:Organization
Organization Name:PROFESSIONAL ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-424-1408
Mailing Address - Street 1:131 TUCKER ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4055
Mailing Address - Country:US
Mailing Address - Phone:731-424-1408
Mailing Address - Fax:931-388-7119
Practice Address - Street 1:131 TUCKER AVENUE
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4055
Practice Address - Country:US
Practice Address - Phone:731-424-1408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3607936Medicaid
TN3607936Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
TN3701041Medicare ID - Type UnspecifiedMEDICARE MD GROUP