Basic Information
| Provider Information | |||||||||
| NPI: | 1598269524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEY WEST ANESTHESIA SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
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| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 COLLEGE RD | ||||||||
| Address2: | |||||||||
| City: | KEY WEST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330404342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLEMENS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6608265960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD, PHD | ||||||||
| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 024919700 | 05 | FL | MEDICAID |