Provider Demographics
NPI:1366845554
Name:MISSISSIPPI ANESTHESIA GROUP, LLC
Entity type:Organization
Organization Name:MISSISSIPPI ANESTHESIA GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:601-668-5628
Mailing Address - Street 1:2714 W OXFORD LOOP
Mailing Address - Street 2:STE 161
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5711
Mailing Address - Country:US
Mailing Address - Phone:662-550-4299
Mailing Address - Fax:662-580-4324
Practice Address - Street 1:145 SANCTUARY LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-6601
Practice Address - Country:US
Practice Address - Phone:601-855-7440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR598755367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty