Provider Demographics
NPI:1063782696
Name:MAK ANESTHESIA WESTSIDE LLC
Entity type:Organization
Organization Name:MAK ANESTHESIA WESTSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEIGANDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-702-1806
Mailing Address - Street 1:1635 OLD 41 HIGHWAY NW, SUITE 112-328
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152
Mailing Address - Country:US
Mailing Address - Phone:770-702-1806
Mailing Address - Fax:770-693-0810
Practice Address - Street 1:1269 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3873
Practice Address - Country:US
Practice Address - Phone:770-922-0505
Practice Address - Fax:770-922-1870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty