Basic Information
| Provider Information | |||||||||
| NPI: | 1245850957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK RIVER ANESTHESIA STAFFING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5623 E DUNBAR RD | ||||||||
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| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Practice Location | |||||||||
| Address1: | 7245 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILKINSON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7342413891 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.