Provider Demographics
NPI:1720329220
Name:DHOM ANESTHESIA ADMINISTRATIVE SERVICES LLC
Entity Type:Organization
Organization Name:DHOM ANESTHESIA ADMINISTRATIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-869-0397
Mailing Address - Street 1:1102 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5341
Mailing Address - Country:US
Mailing Address - Phone:810-869-0397
Mailing Address - Fax:
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061430207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4574510Medicaid
0N87180Medicare PIN
H21528Medicare UPIN