Basic Information
| Provider Information | |||||||||
| NPI: | 1427233873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARION COUNTY ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2829 E HIGHWAY 76 | ||||||||
| Address2: | |||||||||
| City: | MULLINS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295746035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434312542 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2008 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CRNA/MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8434312542 | ||||||||
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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 | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | GP0097 | 05 | SC | MEDICAID | DN4700 | 01 | SC | RR MEDICARE | OTHER |