Basic Information
| Provider Information | |||||||||
| NPI: | 1881998110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND ANESTHESIA | ||||||||
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| OtherOrganizationName: | HEARTLAND ANESTHESIA , L.L.C. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 410272 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641410272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341350 | ||||||||
| FaxNumber: | 9132341108 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660483235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136841100 | ||||||||
| FaxNumber: | 9136841239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9135220889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200689230A | 05 | KS | MEDICAID | DR1786 | 01 | KS | RR MEDICARE | OTHER | 1881998110 | 05 | MO | MEDICAID |