Basic Information
| Provider Information | |||||||||
| NPI: | 1821257783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA PAIN SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 E LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625213810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174645839 | ||||||||
| FaxNumber: | 2174641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625213810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174645839 | ||||||||
| FaxNumber: | 2174641693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | FANCHER | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2174645839 | ||||||||
| 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 | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.