Healthcare Provider Details

I. General information

NPI: 1902036734
Provider Name (Legal Business Name): INNOVATIVE ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200 STE 201 PEND OREILLE SURGERY CENTER
PONDERAY ID
83852-5005
US

IV. Provider business mailing address

PO BOX 591
SAGLE ID
83860-0591
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-8194
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-491A
License Number StateID

VIII. Authorized Official

Name: BRUCE DEMKO
Title or Position: PARTNER
Credential:
Phone: 208-265-3534