Healthcare Provider Details

I. General information

NPI: 1699754242
Provider Name (Legal Business Name): MID-LAND ANESTHESIA ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

IV. Provider business mailing address

RR 1 BOX 366
WILLIAMSVILLE MO
63967-9724
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateMO

VIII. Authorized Official

Name: PATRICK ROBERTS
Title or Position: PRESIDENT
Credential: CPA
Phone: 573-686-5550