Provider Demographics
NPI:1487081436
Name:EPIX ANESTHESIA OF CENTRAL ILLINOIS LLC
Entity type:Organization
Organization Name:EPIX ANESTHESIA OF CENTRAL ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-580-1349
Mailing Address - Street 1:1080 HOLCOMB BRIDGE RD STE 330
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4346
Mailing Address - Country:US
Mailing Address - Phone:678-580-1349
Mailing Address - Fax:770-559-1231
Practice Address - Street 1:12935 GREGORY ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2428
Practice Address - Country:US
Practice Address - Phone:678-580-1349
Practice Address - Fax:770-559-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-07
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty