Basic Information
Provider Information | |||||||||
NPI: | 1457778169 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOBILE ANESTHESIA CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOBILE ANESTHESIA CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8717 W 110TH ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662102144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9134282900 | ||||||||
FaxNumber: | 9134282951 | ||||||||
Practice Location | |||||||||
Address1: | 8717 W 110TH ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662102144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9134282900 | ||||||||
FaxNumber: | 9134282951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2014 | ||||||||
LastUpdateDate: | 03/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRINDSTAFF | ||||||||
AuthorizedOfficialFirstName: | RYAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9134282900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 100000590B | 05 | KS |   | MEDICAID | 00053011 | 01 | MO | BLUECROSS/BLUESHIELD | OTHER | 500513601 | 05 | MO |   | MEDICAID | 100000590A | 05 | KS |   | MEDICAID |