Healthcare Provider Details

I. General information

NPI: 1104358464
Provider Name (Legal Business Name): SUMMIT ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 EAGAN WOODS DRIVE SUITE 300
EAGAN MN
55121-1466
US

IV. Provider business mailing address

710 COMMERCE DR SUITE 200
WOODBURY MN
55125-4919
US

V. Phone/Fax

Practice location:
  • Phone: 651-730-3532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ADAM BERRY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 651-968-5333