Basic Information
| Provider Information | |||||||||
| NPI: | 1114266749 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-AMERICAN ANESTHESIA AND PAIN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600450689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476152200 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 UTICA RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527221626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5637425000 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2013 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | GONION | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8476152200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RHIT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 34558 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | 34558 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.