Provider Demographics
NPI:1578656948
Name:CHARLESTON ANESTHESIA GROUP LLC
Entity Type:Organization
Organization Name:CHARLESTON ANESTHESIA GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-884-1830
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:LANDISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17538-0093
Mailing Address - Country:US
Mailing Address - Phone:800-800-1617
Mailing Address - Fax:866-759-5426
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5733
Practice Address - Country:US
Practice Address - Phone:843-402-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC122771300OtherDEPT OF LABOR
SCDA3021OtherRR MEDICARE
SCGP3724Medicaid
SC83059945OtherBLUE SHEILD
SC7687Medicare PIN