Provider Demographics
NPI:1801291646
Name:BLUE WATER ANESTHESIA, LLC
Entity type:Organization
Organization Name:BLUE WATER ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-467-7526
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0700
Mailing Address - Country:US
Mailing Address - Phone:770-979-0900
Mailing Address - Fax:
Practice Address - Street 1:2175 NORTH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2630
Practice Address - Country:US
Practice Address - Phone:770-979-0900
Practice Address - Fax:770-979-2852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191954367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty