Provider Demographics
NPI:1265518849
Name:SOUTHEAST GEORGIA ANESTHESIA LLC
Entity type:Organization
Organization Name:SOUTHEAST GEORGIA ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-553-1659
Mailing Address - Street 1:PO BOX 18824
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27419-8824
Mailing Address - Country:US
Mailing Address - Phone:336-553-1659
Mailing Address - Fax:336-553-3994
Practice Address - Street 1:410 DARLING AVE
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5246
Practice Address - Country:US
Practice Address - Phone:336-553-1659
Practice Address - Fax:336-553-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA999314012AMedicaid
GAGRP7877Medicare PIN
GADF2706Medicare PIN
GADF2706Medicare ID - Type UnspecifiedMEDICARE RR PROVIDER #