Basic Information
| Provider Information | |||||||||
| NPI: | 1366431132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRANT ANESTHESIA SERVICES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5350 FRANTZ RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446355 | ||||||||
| FaxNumber: | 6145446350 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S GRANT AVE | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145668808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 09/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | WUESTEWALD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | REV CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6145665107 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2503644 | 05 | OH | MEDICAID | 2503704 | 05 | OH | MEDICAID | 2503759 | 05 | OH | MEDICAID | 2503919 | 05 | OH | MEDICAID |