1295842623 NPI number — RED RIVER ANESTHESIA P C

Table of content: (NPI 1295842623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295842623 NPI number — RED RIVER ANESTHESIA P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED RIVER ANESTHESIA P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295842623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1296
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARSAW
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46581-1296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-268-9640
Provider Business Mailing Address Fax Number:
574-268-0684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 ST FRANCIS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRECKENRIDGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56520-1025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-643-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPLICHAL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
574-268-9640

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CG1606 . This is a "PALMETTO GPA - MEDICARE RAIL ROAD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22L73RE . This is a "BLUE CROSS BLUE SHIELD BLUE PLUS OF MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: CG1606 . This is a "PALMETTO GPA - MEDICARE RAIL ROAD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 053783700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11090 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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