Provider Demographics
NPI:1942302617
Name:SOUTHCREST ANESTHESIA SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTHCREST ANESTHESIA SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:662-349-9136
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0015
Mailing Address - Country:US
Mailing Address - Phone:662-349-9136
Mailing Address - Fax:662-349-0677
Practice Address - Street 1:7580 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5657
Practice Address - Country:US
Practice Address - Phone:662-349-9136
Practice Address - Fax:662-349-0677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR691259367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015237Medicaid
MS09015237Medicaid
MSC03305Medicare ID - Type Unspecified