# GREENBRIER VALLEY ANESTHESIA LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902849706
- **Authorized official:** JENNIFER L JACKSON (SENIOR DIR. OF PROVIDER ENROLLMENT)
- **Authorized official phone:** (615) 465-3334

## Contact information

- **Practice address:** 1320 MAPLEWOOD AVE, RONCEVERTE, WV 24970-8016
- **Practice address phone:** (304) 647-6549
- **Mailing address:** PO BOX 689022, FRANKLIN, TN 37068-9022
- **Mailing address phone:** (615) 465-7354
- **Mailing address fax:** (615) 465-7389

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207L00000X | Anesthesiology Physician | — | NULL | — |
| 207L00000X | Anesthesiology Physician | — | — | — |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |
| 367500000X | Certified Registered Nurse Anesthetist | — | NULL | — |
| 367500000X | Certified Registered Nurse Anesthetist | — | — | — |

## Other

- **Enumeration date:** 06/13/2006
- **Last updated:** 04/12/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 001711970 | BCBS PHYSICIAN | WV |
| 01 | — | 001711974 | BCBS CRNA | WV |
| 05 | — | 0106041001 | — | WV |