Basic Information
Provider Information | |||||||||
NPI: | 1063487056 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ANESTHESIA SERVICE INC PS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2329 | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982737329 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603366517 | ||||||||
FaxNumber: | 3604662682 | ||||||||
Practice Location | |||||||||
Address1: | 1415 E KINCAID ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982744126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603366517 | ||||||||
FaxNumber: | 3604662682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MELDAHL | ||||||||
AuthorizedOfficialFirstName: | CHAR | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | GROUP ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3604662542 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X |   | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0743 | 01 | WA | REGENCE BLUE SHIELD | OTHER | CD2096 | 01 | WA | RAILROAD MEDICARE | OTHER | 0061300 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER | 22989001 | 01 | WA | GROUP HEALTH | OTHER | 7844400 | 05 | WA |   | MEDICAID | TRICARE | 01 | WA | A001 | OTHER |