Basic Information
| Provider Information | |||||||||
| NPI: | 1073787818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORGAN MOUNTAIN ANESTHESIA CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 S MAIN ST | ||||||||
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| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639015831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4311 E LOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880118255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055567600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | YAPHET | ||||||||
| AuthorizedOfficialFirstName: | MARCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5736865550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R40661 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.