Provider Demographics
NPI:1659316958
Name:COLLETON MEDICAL ANESTHESIA, LLC
Entity Type:Organization
Organization Name:COLLETON MEDICAL ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:H
Authorized Official - Middle Name:H
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-782-2602
Mailing Address - Street 1:501 ROBERTSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2787
Mailing Address - Country:US
Mailing Address - Phone:843-782-2000
Mailing Address - Fax:843-549-6254
Practice Address - Street 1:501 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2787
Practice Address - Country:US
Practice Address - Phone:843-782-2000
Practice Address - Fax:843-549-6254
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALTERBORO COMMUNITY HOSPITAL, INC D/B/A COLLETON MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3871Medicaid
SC7925Medicare ID - Type UnspecifiedCARE