Provider Demographics
NPI:1548696925
Name:GULF ANESTHESIA SERVICES LLC
Entity type:Organization
Organization Name:GULF ANESTHESIA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:BENEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:228-860-0820
Mailing Address - Street 1:PO BOX 24023
Mailing Address - Street 2:DEPT 03-084
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4023
Mailing Address - Country:US
Mailing Address - Phone:228-860-0820
Mailing Address - Fax:228-731-3446
Practice Address - Street 1:12504 WINDANCE DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-7780
Practice Address - Country:US
Practice Address - Phone:228-860-0820
Practice Address - Fax:228-731-3446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863937367500000X
MSR867945367500000X
MSR874062367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty