Basic Information
| Provider Information | |||||||||
| NPI: | 1306894241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALLAS ANESTHESIA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3015 N BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965330 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965330 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | FICHTER | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3149965330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 503089500 | 05 | MO | MEDICAID |