Basic Information
| Provider Information | |||||||||
| NPI: | 1790738854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOSEPH VALLEY ANESTHESIA P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1742 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466341742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742333123 | ||||||||
| FaxNumber: | 5742333125 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 HOLY CROSS PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
| FaxNumber: | 5742333125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | BEASLEY | ||||||||
| AuthorizedOfficialFirstName: | DARRYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5742333123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200055220A | 05 | IN | MEDICAID |