Provider Demographics
NPI:1144253840
Name:ANESTHESIOLOGY MEDICAL SERVICES PSC
Entity type:Organization
Organization Name:ANESTHESIOLOGY MEDICAL SERVICES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:TITLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-684-8611
Mailing Address - Street 1:2211 MAYFAIR AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301
Mailing Address - Country:US
Mailing Address - Phone:270-684-8611
Mailing Address - Fax:270-684-1186
Practice Address - Street 1:2211 MAYFAIR AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-684-8611
Practice Address - Fax:270-684-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1172699OtherPASSPORT
221317OtherANTHEM
KY65937450Medicaid
KY74900408OtherMEDICAID CRNAS
KY74900408OtherMEDICAID CRNAS