Basic Information
| Provider Information | |||||||||
| NPI: | 1427009406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STARK COUNTY ANESTHESIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4665 DOUGLAS CIR NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447183673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304995700 | ||||||||
| FaxNumber: | 3304984229 | ||||||||
| Practice Location | |||||||||
| Address1: | 4665 DOUGLAS CIR NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447183673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304995700 | ||||||||
| FaxNumber: | 3304984229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3304995700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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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 | 0809316 | 05 | OH | MEDICAID | CJ0836 | 01 | MEDICARE RAILROAD | OTHER |