Basic Information
| Provider Information | |||||||||
| NPI: | 1588142228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR PEAKS ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3850 E BASELINE RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064404 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3850 E BASELINE RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | CROUSE | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9999999999 | ||||||||
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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 |
No ID Information.