Healthcare Provider Details

I. General information

NPI: 1629211057
Provider Name (Legal Business Name): MIDWEST ANESTHESIA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 3RD AVE
JASPER IN
47546-3601
US

IV. Provider business mailing address

602 3RD AVE PO BOX 0488
JASPER IN
47546-3601
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-9617
  • Fax: 812-634-7152
Mailing address:
  • Phone: 812-482-9617
  • Fax: 812-634-7152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28080901
License Number StateIN

VIII. Authorized Official

Name: MISS CYNTHIA D GRESS
Title or Position: OWNER/PRESIDENT
Credential: CRNA
Phone: 812-482-9617