Basic Information
| Provider Information | |||||||||
| NPI: | 1700166592 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE SKY ANESTHESIA PLLC | ||||||||
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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: | 1 E CLARK BASS BLVD | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9189160574 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 616341700 | 01 | OK | US DEPT OF LABOR | OTHER | 200389740A | 05 | OK | MEDICAID |