Basic Information
| Provider Information | |||||||||
| NPI: | 1699845164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER CITIES ANESTHESIA PLLC | ||||||||
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| OtherOrganizationName: | RIVER CITIES ANESTHESIA INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 610041 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752610041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396100775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045261031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | EICHENHOLZ | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2146870001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000742300 | 05 | WV | MEDICAID | 1721135 | 01 | OH | OH BLUE CROSS PROVIDER # | OTHER | 1710227 | 01 | WV | BLUE CROSS WV PROVIDER # | OTHER |