Basic Information
| Provider Information | |||||||||
| NPI: | 1679512362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOSES TAYLOR HOSPITAL | ||||||||
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| OtherOrganizationName: | MTH ANESTHESIA | ||||||||
| 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: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 QUINCY AVE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185101724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703402977 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRITTAIN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5703402991 | ||||||||
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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 | DB5577 | 01 | RAILROAD MEDICARE | OTHER | 001626781 | 01 | PA | BLUE CROSS OF PA | OTHER | 119482401 | 01 | PA | US DEPT LABOR COAL MINERS | OTHER | 2578705 | 01 | PA | AETNA | OTHER |