Provider Demographics
NPI:1063513653
Name:FAST TRACK ANESTHESIA
Entity type:Organization
Organization Name:FAST TRACK ANESTHESIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:PALUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-596-2387
Mailing Address - Street 1:1008 TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2801
Mailing Address - Country:US
Mailing Address - Phone:304-596-2378
Mailing Address - Fax:304-596-2388
Practice Address - Street 1:1008 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2801
Practice Address - Country:US
Practice Address - Phone:304-596-2378
Practice Address - Fax:304-596-2388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002630Medicaid
WV3810002630Medicaid