MEDICARE: INDEP ANESTHESIA SERVICES OF LA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

General Provider Information

NPI Number	:	1275230443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEP ANESTHESIA SERVICES OF LA LLC

Provider Business Mailing Address
First Line	:	PO BOX 570
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-0570
Country	:	US
Telephone Number	:	847-466-4358
Fax Number	:

Provider Business Practice Location Address
First Line	:	619 CALEDONIA DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7131
Country	:	US
Telephone Number	:	318-675-7737
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MR. JASON WHITE
Credential	:	CRNA
Telephone Number	:	318-675-7737

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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