Healthcare Provider Details

I. General information

NPI: 1053699736
Provider Name (Legal Business Name): MOBILE ANESTHESIOLOGISTS OF MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8420 W BRYN MAWR AVE SUITE 300
CHICAGO IL
60631-3479
US

IV. Provider business mailing address

8420 W BRYN MAWR AVE SUITE 300
CHICAGO IL
60631-3479
US

V. Phone/Fax

Practice location:
  • Phone: 773-355-5300
  • Fax: 773-714-1353
Mailing address:
  • Phone: 773-355-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2011012170
License Number StateMO

VIII. Authorized Official

Name: DR. ROBERT S GERSON
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 480-276-2667