Provider Demographics
NPI:1679544183
Name:GRENADA ANESTHESIOLOGY INC.
Entity Type:Organization
Organization Name:GRENADA ANESTHESIOLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-227-7336
Mailing Address - Street 1:PO BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-395-4110
Practice Address - Street 1:960 AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5230
Practice Address - Country:US
Practice Address - Phone:662-227-7336
Practice Address - Fax:662-227-7000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700493OtherMEDICARE GROUP #