Basic Information
Provider Information | |||||||||
NPI: | 1952328767 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MITCHELL ANESTHESIA PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5126 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053351952 | ||||||||
FaxNumber: | 6053739971 | ||||||||
Practice Location | |||||||||
Address1: | 525 N FOSTER ST | ||||||||
Address2: |   | ||||||||
City: | MITCHELL | ||||||||
State: | SD | ||||||||
PostalCode: | 573012966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6059952000 | ||||||||
FaxNumber: | 6059955645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 02/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VAN ERDEWYK | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 6059952000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0250 | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 0003527 | 01 | SD | BCBS - GROUP | OTHER | 10025039000 | 05 | NE |   | MEDICAID |