Provider Demographics
NPI:1750594347
Name:SECURUS ANESTHESIA LLC
Entity type:Organization
Organization Name:SECURUS ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SANTAMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-273-9096
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:1111 BEARDS HILL RD
Practice Address - Street 2:SUITE 700
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-2232
Practice Address - Country:US
Practice Address - Phone:410-273-9096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404862800Medicaid
MD612371800OtherUS DEPT OF LABOR
MD404862800Medicaid
MD475PMedicare PIN
MD612371800OtherUS DEPT OF LABOR