Healthcare Provider Details

I. General information

NPI: 1043757487
Provider Name (Legal Business Name): ANESTHESIA ASSOCIATES OF SOUTHERN ILLINOIS SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GOOD SAMARITAN WAY STE 200
MOUNT VERNON IL
62864-2476
US

IV. Provider business mailing address

2 GOOD SAMARITAN WAY SUITE 205
MOUNT VERNON IL
62864-2408
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-5703
  • Fax: 618-899-5704
Mailing address:
  • Phone: 618-899-3869
  • Fax: 618-899-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: AMANDA KLOPFENSTEIN
Title or Position: FINANCIAL OPERATIONS MANAGER
Credential:
Phone: 314-368-5849