Basic Information
| Provider Information | |||||||||
| NPI: | 1477567246 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND ANESTHESIOLOGY SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1501 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008777078 | ||||||||
| FaxNumber: | 3077397446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | DOMSKY | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077397218 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.