Provider Demographics
NPI:1629317722
Name:SOUTHERN ANESTHESIA CONSULTANTS OF GA, LLC
Entity Type:Organization
Organization Name:SOUTHERN ANESTHESIA CONSULTANTS OF GA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:AGUDELO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:800-394-0131
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:800-394-0131
Mailing Address - Fax:478-254-8119
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:800-394-0131
Practice Address - Fax:478-254-8119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty