Basic Information
| Provider Information | |||||||||
| NPI: | 1215105143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND ANESTHESIA CONSULTANTS PSC CRNA GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 639 NORTH MULBERRY STREET | ||||||||
| Address2: | CRNA GROUP | ||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707374600 | ||||||||
| FaxNumber: | 2707371722 | ||||||||
| Practice Location | |||||||||
| Address1: | 639 NORTH MULBERRY STREET | ||||||||
| Address2: | CRNA GROUP | ||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707374600 | ||||||||
| FaxNumber: | 2707371722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | SPALDING | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2707374600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OFFICE MANAGER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA GROUP | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000051346 | 01 | ANTHEM | OTHER | 000000051345 | 01 | ANTHEM | OTHER | 2434372000 | 01 | PASS ADV | OTHER | 2434376000 | 01 | PASS ADV | OTHER | 74900242 | 05 | KY | MEDICAID | 000000051347 | 01 | ANTHEM | OTHER | 1063437 | 01 | PASSPORT GROUP | OTHER | 1063448 | 01 | PASSPORT | OTHER | 2434377000 | 01 | PASS ADV | OTHER | 1063444 | 01 | PASSPORT | OTHER | 1063453 | 01 | PASSPORT | OTHER | 1063454 | 01 | PASSPORT | OTHER | 2434373000 | 01 | PASS ADV | OTHER | 8861 | 01 | ANTHEM | OTHER | 000000051352 | 01 | ANTHEM | OTHER | 2434370000 | 01 | PASSPORT ADVANTAGE GRP | OTHER | 1063446 | 01 | PASSPORT | OTHER | 2434374000 | 01 | PASS ADV | OTHER |