Basic Information
| Provider Information | |||||||||
| NPI: | 1184706251 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFREY D PIERCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHWEST ANESTHESIA SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 COMPASSION WAY | ||||||||
| Address2: | |||||||||
| City: | DODGEVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535331956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6089352711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8884439902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 39754747701 | 01 | WI | UNITY HEALTH PLAN | OTHER | 43419200 | 05 | WI | MEDICAID |