Provider Demographics
NPI:1760989925
Name:DREAM TEAM ANESTHESIA ASSOCIATES INC
Entity Type:Organization
Organization Name:DREAM TEAM ANESTHESIA ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNICE
Authorized Official - Middle Name:H
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:478-929-0036
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-0629
Mailing Address - Country:US
Mailing Address - Phone:855-491-8869
Mailing Address - Fax:478-352-0095
Practice Address - Street 1:807 CARROLL ST STE C-2002
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3311
Practice Address - Country:US
Practice Address - Phone:855-491-8869
Practice Address - Fax:478-352-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ05682OtherUPIN
GARN134488OtherSTATE LICENSE
GA664068606BMedicaid