Healthcare Provider Details

I. General information

NPI: 1134570153
Provider Name (Legal Business Name): CARDINAL ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 10/04/2023
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51050 BITTERSWEET RD
GRANGER IN
46530-7879
US

IV. Provider business mailing address

51050 BITTERSWEET RD
GRANGER IN
46530-7879
US

V. Phone/Fax

Practice location:
  • Phone: 718-208-0446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RONI AIZIGOV
Title or Position: PRESIDENT AND CEO
Credential: CRNA
Phone: 718-208-0446