Basic Information
| Provider Information | |||||||||
| NPI: | 1780228155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLDE CABIN ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5393 | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601975393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
| FaxNumber: | 9413283997 | ||||||||
| Practice Location | |||||||||
| Address1: | 11525 OLDE CABIN RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631417146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144009999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2019 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEINSTOCK | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3144009999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.