Basic Information
| Provider Information | |||||||||
| NPI: | 1013973296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE RIVER ANESTHESIA ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842120 | ||||||||
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| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641842120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002778151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 BRANSON LANDING BLVD | ||||||||
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| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656162052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172393392 | ||||||||
| FaxNumber: | 4172393394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | LUDER | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4172393392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 508765401 | 05 | MO | MEDICAID | 200077410A | 05 | OK | MEDICAID | DC8634 | 01 | MO | RAILROAD | OTHER | 194111 | 01 | MO | MISSOURI BCBS | OTHER | 158909002 | 05 | AR | MEDICAID |