Basic Information
| Provider Information | |||||||||
| NPI: | 1881696706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUCK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 CONSORT DR | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630114439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004242 | ||||||||
| FaxNumber: | 6362004243 | ||||||||
| Practice Location | |||||||||
| Address1: | 17050 BAXTER RD | ||||||||
| Address2: | CHESTERFIELD SURGERY CTR. - SUITE 110 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630051422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365370122 | ||||||||
| FaxNumber: | 6365370480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 086233 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 912801057 | 05 | MO | MEDICAID |