Provider Demographics
NPI:1649579749
Name:INDEPENDENT ANESTHESIA LLC
Entity Type:Organization
Organization Name:INDEPENDENT ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-425-2239
Mailing Address - Street 1:6094 14TH ST W
Mailing Address - Street 2:SUITE 189
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-4104
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:1720 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4464
Practice Address - Country:US
Practice Address - Phone:706-623-4271
Practice Address - Fax:706-225-7217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2014-03-05
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
TX=========OtherPPO