Basic Information
Provider Information | |||||||||
NPI: | 1427013812 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WORTHINGTON ANESTHESIA SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 E 10TH ST | ||||||||
Address2: |   | ||||||||
City: | WACONIA | ||||||||
State: | MN | ||||||||
PostalCode: | 553874552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524429770 | ||||||||
FaxNumber: | 9524423630 | ||||||||
Practice Location | |||||||||
Address1: | 1018 6TH AVE | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 561872202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073723292 | ||||||||
FaxNumber: | 5073723254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 04/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERGH | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5073723292 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CRNA | ||||||||
NPICertificationDate: |   |
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 | 61423WO | 01 | MN | BLUE CROSS OF MN | OTHER | 21561 | 01 | MN | HEALTHPARTNERS | OTHER | 0949784 | 05 | IA |   | MEDICAID | 210989100 | 05 | MN |   | MEDICAID |