Healthcare Provider Details

I. General information

NPI: 1003640442
Provider Name (Legal Business Name): MB ANESTHESIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W 1ST ST STE 201
MESA AZ
85201-6653
US

IV. Provider business mailing address

PO BOX 5870
MESA AZ
85211-5870
US

V. Phone/Fax

Practice location:
  • Phone: 480-874-7014
  • Fax: 480-874-7015
Mailing address:
  • Phone: 480-874-7014
  • Fax: 480-874-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MARSHALL B BERGEN
Title or Position: SOLE MBR
Credential: CRNA
Phone: 480-874-7013