Basic Information
| Provider Information | |||||||||
| NPI: | 1275646754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN ANESTHESIOLOGY ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN ANESTHESIOLOGY PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 339 CONSORT DR | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630114439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363869224 | ||||||||
| FaxNumber: | 6363867679 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 S NEW BALLAS RD | ||||||||
| Address2: | DEPT. OF ANESTHESIA | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363869224 | ||||||||
| FaxNumber: | 6363867679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 05/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOHANS | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6363869224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 500477500 | 05 | MO | MEDICAID |