Provider Demographics
NPI:1902866882
Name:EASTERN PANHANDLE ANESTHESIA ASSOCIATES
Entity Type:Organization
Organization Name:EASTERN PANHANDLE ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHAMBLIN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:304-264-8933
Mailing Address - Street 1:109 MOUNT WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:2500 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-264-8933
Practice Address - Fax:304-264-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVCI6384OtherRAILROAD MEDICARE
WV0203593000Medicaid
WV0203593000Medicaid