Organization
GREENBRIER VALLEY ANESTHESIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER L JACKSON (SENIOR DIR. OF PROVIDER ENROLLMENT)
(615) 465-3334
Entity
Organization
Contact information
Practice address
1320 MAPLEWOOD AVE, RONCEVERTE, WV 24970-8016
(304) 647-6549
Mailing address
PO BOX 689022, FRANKLIN, TN 37068-9022
(615) 465-7354
(615) 465-7389
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
—
—
208D00000X
General Practice Physician
Primary
—
—
367500000X
Certified Registered Nurse Anesthetist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001711970
BCBS PHYSICIAN
WV
01
—
001711974
BCBS CRNA
WV
05
—
0106041001
—
WV
Enumeration date
06/13/2006
Last updated
04/12/2022
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