Provider Demographics
NPI:1396135182
Name:PROVIDENCE ANESTHESIA ASSOCIATES, P.A.
Entity type:Organization
Organization Name:PROVIDENCE ANESTHESIA ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:OPPONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:301-755-9500
Mailing Address - Street 1:6911 LAUREL BOWIE RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6911 LAUREL BOWIE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1712
Practice Address - Country:US
Practice Address - Phone:301-755-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-31
Last Update Date:2016-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD039935207L00000X
MDD0066706207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty