Healthcare Provider Details

I. General information

NPI: 1114266749
Provider Name (Legal Business Name): MID-AMERICAN ANESTHESIA AND PAIN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 UTICA RIDGE RD
BETTENDORF IA
52722-1626
US

IV. Provider business mailing address

PO BOX 689
LAKE FOREST IL
60045-0689
US

V. Phone/Fax

Practice location:
  • Phone: 563-742-5000
  • Fax: 847-615-2858
Mailing address:
  • Phone: 847-615-2200
  • Fax: 847-615-2858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number34558
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number34558
License Number StateIA

VIII. Authorized Official

Name: MRS. CHERYL L GONION
Title or Position: CREDENTIALING
Credential: RHIT
Phone: 847-615-2200