Basic Information
| Provider Information | |||||||||
| NPI: | 1003916107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST IOWA ANESTHESIA PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 SHERWOOD DR | ||||||||
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| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442203 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 S GEAR AVE | ||||||||
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| City: | W BURLINGTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 526551679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3197681000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | BAINBRIDGE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3197681000 | ||||||||
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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.