Provider Demographics
NPI:1831383264
Name:ANESTHESIA SERVICES OF JACKSONHOLE, P.C.
Entity type:Organization
Organization Name:ANESTHESIA SERVICES OF JACKSONHOLE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:307-734-6956
Mailing Address - Street 1:970 W BROADWAY # 378
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9475
Mailing Address - Country:US
Mailing Address - Phone:307-734-6956
Mailing Address - Fax:
Practice Address - Street 1:970 W BROADWAY # 378
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9475
Practice Address - Country:US
Practice Address - Phone:307-734-6956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6301A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty