Basic Information
| Provider Information | |||||||||
| NPI: | 1043511447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TB ANESTHESIA ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HOLMAN RD | ||||||||
| Address2: | |||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652703202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736862139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2103 SILVA LN | ||||||||
| Address2: | |||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652703660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602631266 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | BUSICK | ||||||||
| AuthorizedOfficialFirstName: | TAMRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5736865550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043511447 | 01 | MO | BCBS | OTHER | 1043511447 | 05 | MO | MEDICAID |