Basic Information
| Provider Information | |||||||||
| NPI: | 1184055097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONROE ANESTHESIA SERVICES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 724 | ||||||||
| Address2: | |||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833180724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083127321 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 HILAND AVE | ||||||||
| Address2: | |||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833182688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 12/02/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONROE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083127321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CRNA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N-31144 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1891877858 | 05 | ID | MEDICAID |