Provider Demographics
NPI:1811559784
Name:MBSC ANESTHESIA, LLC
Entity Type:Organization
Organization Name:MBSC ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:K
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-334-0961
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0013
Mailing Address - Country:US
Mailing Address - Phone:800-208-6014
Mailing Address - Fax:706-850-7733
Practice Address - Street 1:827 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-286-2020
Practice Address - Fax:843-286-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty