Provider Demographics
NPI:1881875920
Name:MEMORIAL ANESTHESIA, LLC
Entity type:Organization
Organization Name:MEMORIAL ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-829-7683
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:MT. AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771
Mailing Address - Country:US
Mailing Address - Phone:301-829-7683
Mailing Address - Fax:301-829-7694
Practice Address - Street 1:8262 ATLEE RD.
Practice Address - Street 2:MOB 3 #100
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116
Practice Address - Country:US
Practice Address - Phone:804-746-6969
Practice Address - Fax:804-746-6950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207LP2900X
207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB07522Medicare UPIN
C10378Medicare UPIN