Basic Information
| Provider Information | |||||||||
| NPI: | 1194224303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ANESTHESIA SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 570 | ||||||||
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| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600450570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004446110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1575 20TH ST NW # 205A | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550212930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072096226 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2018 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BERUBE | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6126167731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1731 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1205223989 | 05 | MN | MEDICAID |