Healthcare Provider Details

I. General information

NPI: 1912578667
Provider Name (Legal Business Name): ICELAND ANESTHESIA MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 N 7TH ST
TERRE HAUTE IN
47804-2706
US

IV. Provider business mailing address

PO BOX 69394
BALTIMORE MD
21264-9394
US

V. Phone/Fax

Practice location:
  • Phone: 833-352-0096
  • Fax:
Mailing address:
  • Phone: 833-352-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JUDY PFEIFFER
Title or Position: DIRECTOR OF MEDICAL STAFF SERVICES
Credential:
Phone: 833-352-0096