Provider Demographics
NPI:1639950140
Name:PRODIGY OFFICE ANESTHESIA, LLC
Entity Type:Organization
Organization Name:PRODIGY OFFICE ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:304-741-4957
Mailing Address - Street 1:917 COUNTRY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8492
Mailing Address - Country:US
Mailing Address - Phone:304-741-4957
Mailing Address - Fax:
Practice Address - Street 1:1710 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2727
Practice Address - Country:US
Practice Address - Phone:606-528-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty