Healthcare Provider Details

I. General information

NPI: 1639568058
Provider Name (Legal Business Name): BLACK MOUNTAIN ANESTHESIA GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 HOSPITAL LOOP
CRAIG CO
81625-8750
US

IV. Provider business mailing address

1255 LECUYER DR
CRAIG CO
81625-1438
US

V. Phone/Fax

Practice location:
  • Phone: 970-824-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0205032
License Number StateCO

VIII. Authorized Official

Name: MR. JOHN KEITH PRESCOTT
Title or Position: CRNA
Credential: MSNA
Phone: 918-850-5607