Provider Demographics
NPI:1609140870
Name:ASTORIA OF MIDDLE GA LLC
Entity Type:Organization
Organization Name:ASTORIA OF MIDDLE GA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:AGUDELO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:478-787-9153
Mailing Address - Street 1:403 LAKEVIEW PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-6127
Mailing Address - Country:US
Mailing Address - Phone:478-787-9153
Mailing Address - Fax:
Practice Address - Street 1:403 LAKEVIEW PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-6127
Practice Address - Country:US
Practice Address - Phone:478-787-9153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty