Provider Demographics
NPI:1679933774
Name:EXCALIBUR ANESTHESIA ASSOCIATES INC
Entity type:Organization
Organization Name:EXCALIBUR ANESTHESIA ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-760-9360
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-0776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 SIGMAN RD NE
Practice Address - Street 2:SUITE 120
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3812
Practice Address - Country:US
Practice Address - Phone:770-760-9360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty