Provider Demographics
NPI:1972743987
Name:PLATINUM ANESTHESIA COASTAL, LLC
Entity Type:Organization
Organization Name:PLATINUM ANESTHESIA COASTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-605-9961
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:TENNILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31089-0068
Mailing Address - Country:US
Mailing Address - Phone:800-605-9961
Mailing Address - Fax:800-782-0704
Practice Address - Street 1:200 N RIVER ST
Practice Address - Street 2:DEPT OF ANESTHESIA
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-1659
Practice Address - Country:US
Practice Address - Phone:912-739-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2011-09-13
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
GA568167122AMedicaid
GADO7086OtherMEDICARE RAILROAD
GADO7086OtherMEDICARE RAILROAD