Basic Information
| Provider Information | |||||||||
| NPI: | 1700836665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSEE | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MACARTHUR BOULEVARD | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198367040 | ||||||||
| FaxNumber: | 2195131127 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463213901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
| FaxNumber: | 2195131127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 12/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 28094042A | IN | Y | Other Service Providers | Specialist | 367500000X | 28094042A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000081287 | 01 | IN | ANTHEM BCBS | OTHER | 200043230A | 05 | IN | MEDICAID |