Basic Information
| Provider Information | |||||||||
| NPI: | 1538106521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTICELLO-BIG LAKE ANESTHESIOLOGY | ||||||||
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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: | 1013 HART BLVD | ||||||||
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| City: | MONTICELLO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553628575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632712303 | ||||||||
| FaxNumber: | 7632954593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | FRIESEN | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7632712303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 302G4MO | 01 | MN | BLUE CROSS OF MN | OTHER | 111217 | 01 | MN | HEALTHPARTNERS | OTHER | 136709 | 01 | MN | UCARE/MANAGED CARE | OTHER |