Basic Information
| Provider Information | |||||||||
| NPI: | 1386758654 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN FITZGIBBON MEMORIAL HOSPITAL INC. | ||||||||
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| OtherOrganizationName: | FITZGIBBON ANESTHESIA GROUP | ||||||||
| 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: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 S HIGHWAY 65 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608867431 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6608867431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 00617033 | 01 | MO | BLUE CROSS OF KANSAS CITY | OTHER | 215045 | 01 | MO | BLUE CROSS OF MO-FEDERAL | OTHER | 501547608 | 05 | MO | MEDICAID |