Healthcare Provider Details

I. General information

NPI: 1013966506
Provider Name (Legal Business Name): TRAVERSE ANESTHESIA ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 6TH ST MUNSON MEDICAL CENTER/TRAVERSE ANESTHESIA ASSOCIATES, P
TRAVERSE CITY MI
49684-2349
US

IV. Provider business mailing address

4100 PARK FOREST DR SUITE 210
TRAVERSE CITY MI
49684-7331
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-5770
  • Fax: 231-935-0747
Mailing address:
  • Phone: 231-935-5770
  • Fax: 231-935-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MS. NIKKI KILLIAN
Title or Position: BUSINESS OFFICE COORDINATOR
Credential:
Phone: 231-935-5770