Healthcare Provider Details

I. General information

NPI: 1235728403
Provider Name (Legal Business Name): CELEBRITY ANESTHESIA STAFFING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE STE E200
GRAND RAPIDS MI
49546-8371
US

IV. Provider business mailing address

3809 VALLEY VIEW RD BLDG 5
AUSTIN TX
78704-3375
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-9100
  • Fax:
Mailing address:
  • Phone: 512-593-1945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEX KOLASCZ
Title or Position: PARTNER
Credential: CRNA
Phone: 512-593-1945