Healthcare Provider Details

I. General information

NPI: 1013525112
Provider Name (Legal Business Name): SOUTH SHORE ANESTHESIA STAFFING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE STE 235
MARQUETTE MI
49855-5406
US

IV. Provider business mailing address

PO BOX 4419
WOODLAND HILLS CA
91365-4419
US

V. Phone/Fax

Practice location:
  • Phone: 906-361-4901
  • Fax:
Mailing address:
  • Phone: 818-340-9988
  • 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: PETER SKELLENGER
Title or Position: CEO
Credential: MS, CRNA
Phone: 906-399-3611