Provider Demographics
NPI:1285781666
Name:MID-SOUTH ANESTHESIA SERVICE
Entity type:Organization
Organization Name:MID-SOUTH ANESTHESIA SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JUMP
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:256-566-8401
Mailing Address - Street 1:PO BOX 660257
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35266-0257
Mailing Address - Country:US
Mailing Address - Phone:205-979-5882
Mailing Address - Fax:205-979-1248
Practice Address - Street 1:42024 HIGHWAY 195
Practice Address - Street 2:
Practice Address - City:HALEYVILLE
Practice Address - State:AL
Practice Address - Zip Code:35565-7054
Practice Address - Country:US
Practice Address - Phone:205-486-5213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL135617Medicaid
AL102G703344Medicare PIN