Provider Demographics
NPI:1619150745
Name:CLASSIC CITY ANESTHESIA ASSOCIATES
Entity Type:Organization
Organization Name:CLASSIC CITY ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:706-549-2700
Mailing Address - Street 1:1720 EPPS BRIDGE PKWY
Mailing Address - Street 2:SUITE 108-382
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6132
Mailing Address - Country:US
Mailing Address - Phone:706-540-7780
Mailing Address - Fax:
Practice Address - Street 1:1720 EPPS BRIDGE PKWY
Practice Address - Street 2:SUITE 108-382
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6132
Practice Address - Country:US
Practice Address - Phone:706-540-7780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA432CBR612Medicaid