Provider Demographics
NPI:1619149648
Name:PROFESSIONAL ANESTHESIA GROUP, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL ANESTHESIA GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-687-0015
Mailing Address - Street 1:PO BOX 222037
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-2037
Mailing Address - Country:US
Mailing Address - Phone:239-610-0775
Mailing Address - Fax:
Practice Address - Street 1:1500 DIXON ST STE 101
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-7231
Practice Address - Country:US
Practice Address - Phone:540-371-5349
Practice Address - Fax:540-373-1745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZAC7Medicare UPIN