Provider Demographics
NPI: | 1659976751 |
---|---|
Name: | MODERN ANESTHESIA CONSULTANTS, LLC |
Entity Type: | Organization |
Organization Name: | MODERN ANESTHESIA CONSULTANTS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | AR/CREDENTIALING MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CRYSTAL |
Authorized Official - Middle Name: | D |
Authorized Official - Last Name: | GIBSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 615-620-2336 |
Mailing Address - Street 1: | PO BOX 290342 |
Mailing Address - Street 2: | |
Mailing Address - City: | NASHVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37229-0342 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-620-2320 |
Mailing Address - Fax: | 615-620-2323 |
Practice Address - Street 1: | 810 MERRIMAN ST |
Practice Address - Street 2: | |
Practice Address - City: | CONWAY |
Practice Address - State: | AR |
Practice Address - Zip Code: | 72032-4436 |
Practice Address - Country: | US |
Practice Address - Phone: | 501-329-3937 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-12-04 |
Last Update Date: | 2020-12-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Single Specialty |