Basic Information
| Provider Information | |||||||||
| NPI: | 1184603201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUENA VISTA ANESTHESIA ASSOCIATES PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639015831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736865550 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | STORM LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736862139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | KRAUTH | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | MAXINE | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5736865550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 100514 | NE | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 148752 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | D040615 | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0160879 | 05 | IA | MEDICAID | P00252415 | 01 | TRAV RR | OTHER | 40130 | 01 | BCBS | OTHER |