MEDICARE: ADVANCED SPECIALTY ANESTHESIA 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	55036	KS

General Provider Information

NPI Number	:	1821194978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED SPECIALTY ANESTHESIA LLC

Provider Business Mailing Address
First Line	:	PO BOX 388
Second Line	:
City	:	NEWTON
State	:	KS
Zip	:	67114-0388
Country	:	US
Telephone Number	:	316-281-3700
Fax Number	:	316-282-4322

Provider Business Practice Location Address
First Line	:	1201 WAKARUSA DR
Second Line	:	BLDG A SUITE 3
City	:	LAWRENCE
State	:	KS
Zip	:	66049-4722
Country	:	US
Telephone Number	:	785-856-6170
Fax Number	:	785-856-6171

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JEFFERY W GLASGOW
Credential	:	CRNA
Telephone Number	:	785-856-6170

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	05/12/2011

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