NPIMap

Organization Active NPI

Radiance Anesthesia

  • Certified Registered Nurse Anesthetist
  • Macon, GA
National Provider Identifier
1194381236
Registry record updated Dec 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
Legal business name
RADIANCE ANESTHESIA
Practice address
577 Mulberry St Ste 110
Macon, GA 31201-8220
Phone
(240) 469-2179
NPI assigned
May 14, 2019
Last updated
Dec 2, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 2, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Richard E Douberly Jr.NPI 1942311428
Title
Director
Phone
(941) 360-1566

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Certified Registered Nurse AnesthetistGroup: 193400000X SINGLE SPECIALTY GROUP 367500000X Primary

Addresses

Primary practice location

577 Mulberry St Ste 110
Macon, GA 31201-8220

Mailing address

PO Box 850001 Dept 740J
Orlando, FL 32885-0740
Phone (240) 469-2179

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200526003208 GA Part B Supplier - Clinic/Group Practice 5890116032 Receives reassigned benefits from 63 practitioners
Practice locations: Albany, GA; Valdosta, GA; Statesboro, GA; Marietta, GA; Macon, GA; Jonesboro, GA; Athens, GA; Fayetteville, GA…

National Provider Directory

National Provider Directory

Locations

100 Presidential Blvd
Fl 4
Bala Cynwyd, PA 19004
Phone (610) 664-2122

Practitioners & affiliated clinicians

Practitioners 64

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 64

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1557792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1638403200000",
    "number": "1194381236",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 850001 DEPT 740J",
            "city": "ORLANDO",
            "state": "FL",
            "postal_code": "328850740",
            "telephone_number": "240-469-2179"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "577 MULBERRY ST STE 110",
            "city": "MACON",
            "state": "GA",
            "postal_code": "312018220",
            "telephone_number": "240-469-2179"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RADIANCE ANESTHESIA",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-14",
        "last_updated": "2021-12-02",
        "certification_date": "2021-12-02",
        "status": "A",
        "authorized_official_last_name": "DOUBERLY",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "941-360-1566",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Macon, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.