Provider Demographics
NPI:1245287192
Name:CAPITOL ANESTHESIOLOGY, PC
Entity type:Organization
Organization Name:CAPITOL ANESTHESIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-968-9978
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237-0278
Mailing Address - Country:US
Mailing Address - Phone:770-968-9978
Mailing Address - Fax:770-968-9975
Practice Address - Street 1:6649 LAKE DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2354
Practice Address - Country:US
Practice Address - Phone:770-968-9978
Practice Address - Fax:770-968-9975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1665Medicare ID - Type UnspecifiedMEDICARE