1558361089 NPI number — TIERRA ALTA ANESTHESIA

Table of content: (NPI 1558361089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558361089 NPI number — TIERRA ALTA ANESTHESIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIERRA ALTA ANESTHESIA
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:
1558361089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63901-5831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-686-5550
Provider Business Mailing Address Fax Number:
573-686-2136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESPANOLA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87532-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-5550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HOLTZ
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
573-686-5550

Provider Taxonomy Codes

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

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

  • Identifier: NM006869 . This is a "BCBSNM GROUP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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