Provider Demographics
NPI:1912955725
Name:VIDALIA ANESTHESIA ASSOC PC
Entity Type:Organization
Organization Name:VIDALIA ANESTHESIA ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:TOOTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-538-5359
Mailing Address - Street 1:PO BOX 1303
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1303
Mailing Address - Country:US
Mailing Address - Phone:912-538-5359
Mailing Address - Fax:912-538-5228
Practice Address - Street 1:1703 MEADOWS LANE
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-538-5359
Practice Address - Fax:912-538-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033365AMedicaid
GACE7445OtherMEDICARE RAILROAD
GACE7445OtherMEDICARE RAILROAD