Provider Demographics
NPI:1619275401
Name:MARSHALL COUNTY ANESTHESIA PLLC
Entity Type:Organization
Organization Name:MARSHALL COUNTY ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENCY
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-382-3112
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:LYNNVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42063-0015
Mailing Address - Country:US
Mailing Address - Phone:270-382-3112
Mailing Address - Fax:270-382-3112
Practice Address - Street 1:615 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5042
Practice Address - Country:US
Practice Address - Phone:270-527-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY034465367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000703294OtherBLUE CROSS AND BLUE SHIELD
KY7100154520Medicaid
000000703294OtherBLUE CROSS AND BLUE SHIELD