Provider Demographics
NPI:1841760238
Name:MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Entity Type:Organization
Organization Name:MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:828-651-6595
Mailing Address - Street 1:PO BOX 603366
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3366
Mailing Address - Country:US
Mailing Address - Phone:828-213-1500
Mailing Address - Fax:828-681-1575
Practice Address - Street 1:2695 HENDERSONVILLE RD STE 206
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-8576
Practice Address - Country:US
Practice Address - Phone:828-213-1740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION COMMUNITY ANESTHESIOLOGY SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02CG9OtherBC/BS NC