Provider Demographics
NPI:1396739884
Name:PROVIDENCE ANESTHESIOLOGY ASSOCIATES, P.A.
Entity type:Organization
Organization Name:PROVIDENCE ANESTHESIOLOGY ASSOCIATES, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DUCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-749-5800
Mailing Address - Street 1:3735 GLENLAKE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-6866
Mailing Address - Country:US
Mailing Address - Phone:704-749-5800
Mailing Address - Fax:704-626-3272
Practice Address - Street 1:3735 GLENLAKE DR STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-6866
Practice Address - Country:US
Practice Address - Phone:704-749-5800
Practice Address - Fax:704-626-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-11
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890180HMedicaid
NC2312558Medicare ID - Type Unspecified