Provider Demographics
NPI:1265896484
Name:GEORGIA ANESTHESIA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:GEORGIA ANESTHESIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-553-1659
Mailing Address - Street 1:PO BOX 18666
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27419-8666
Mailing Address - Country:US
Mailing Address - Phone:336-553-3999
Mailing Address - Fax:336-553-3994
Practice Address - Street 1:2003 ALICE ST
Practice Address - Street 2:SUITE 2003B
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6209
Practice Address - Country:US
Practice Address - Phone:912-490-3338
Practice Address - Fax:336-553-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty