Provider Demographics
NPI:1669474672
Name:TOMBIGBEE ANESTHESIA LLC
Entity Type:Organization
Organization Name:TOMBIGBEE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-327-6820
Mailing Address - Street 1:PO BOX 9235
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-0017
Mailing Address - Country:US
Mailing Address - Phone:662-327-6820
Mailing Address - Fax:662-327-9388
Practice Address - Street 1:634 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3014
Practice Address - Country:US
Practice Address - Phone:662-327-6820
Practice Address - Fax:662-327-9388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015934Medicaid