Provider Demographics
NPI:1619284197
Name:ADVANCED ANESTHESIA GROUP, PLLC
Entity Type:Organization
Organization Name:ADVANCED ANESTHESIA GROUP, PLLC
Other - Org Name:ADVANCED ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DUONG
Authorized Official - Middle Name:THAI
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-267-5141
Mailing Address - Street 1:PO BOX 62556
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2556
Mailing Address - Country:US
Mailing Address - Phone:302-709-4528
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1006 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2864
Practice Address - Country:US
Practice Address - Phone:304-267-5141
Practice Address - Fax:304-267-5140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9391031Medicare PIN