Provider Demographics
NPI:1710499561
Name:LEGACY ANESTHESIA
Entity Type:Organization
Organization Name:LEGACY ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:DEINDOERFER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:423-639-0941
Mailing Address - Street 1:12186 PAW PAW PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37771-3510
Mailing Address - Country:US
Mailing Address - Phone:423-639-0941
Mailing Address - Fax:423-638-3401
Practice Address - Street 1:12186 PAW PAW PLAINS RD
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-3510
Practice Address - Country:US
Practice Address - Phone:423-639-0941
Practice Address - Fax:423-638-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty