Basic Information
| Provider Information | |||||||||
| NPI: | 1225432909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR PEAKS ANESTHESIA PARTNERS LLC | ||||||||
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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: | 575 RIVERGATE | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813017487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702473537 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | MICHAUD | ||||||||
| AuthorizedOfficialFirstName: | ANDRE-PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ANESTHESIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9706761068 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | DR.0048852 | CO | N | Hospitals | Special Hospital | 207L00000X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 61781339 | 05 | CO | MEDICAID |