MEDICARE: LAG 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

General Provider Information

NPI Number	:	1942750526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAG ANESTHESIA LLC

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

Provider Business Practice Location Address
First Line	:	1601 LOUISVILLE AVE
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71201-6027
Country	:	US
Telephone Number	:	318-998-5555
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAY MASCAGNI
Credential	:	CRNA
Telephone Number	:	318-737-7577

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	10/07/2016

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