Basic Information
| Provider Information | |||||||||
| NPI: | 1144511452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GROVE CITY ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2193 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834032193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085528777 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 PARKWAY DR | ||||||||
| Address2: | |||||||||
| City: | BLACKFOOT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832211667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087855100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 12/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | PURCELL | ||||||||
| AuthorizedOfficialFirstName: | BLAKE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 2083130175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.