Provider Demographics
NPI:1699769232
Name:BRIGHAM ANESTHESIA SOUTH LLC
Entity type:Organization
Organization Name:BRIGHAM ANESTHESIA SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARDNER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-457-5111
Mailing Address - Street 1:35 ALBANY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-7605
Mailing Address - Country:US
Mailing Address - Phone:618-457-5111
Mailing Address - Fax:618-457-6560
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:MEMORIAL HOSPITAL OF CARBONDALE
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-351-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty