1720040165 NPI number — MISSOURI VALLEY ANESTHESIA, PC

Table of content: (NPI 1720040165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720040165 NPI number — MISSOURI VALLEY ANESTHESIA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI VALLEY ANESTHESIA, PC
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:
1720040165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41071-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-291-4800
Provider Business Mailing Address Fax Number:
859-655-8588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 E 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63090-3127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-239-8090
Provider Business Practice Location Address Fax Number:
636-390-7385
Provider Enumeration Date:
04/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NEVETT
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
636-239-8090

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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