Healthcare Provider Details

I. General information

NPI: 1801867510
Provider Name (Legal Business Name): COLLEGE BOULEVARD ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 BAPTISTE DR
PAOLA KS
66071
US

IV. Provider business mailing address

PO BOX 388
NEWTON KS
67114-0388
US

V. Phone/Fax

Practice location:
  • Phone: 913-294-2327
  • Fax:
Mailing address:
  • Phone: 316-281-3700
  • Fax: 316-282-4322

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: PAUL STEPHEN BENNETTS
Title or Position: PARTNER ADMINISTRATOR
Credential: CRNA
Phone: 913-294-2327