Healthcare Provider Details

I. General information

NPI: 1295189082
Provider Name (Legal Business Name): MIDWEST ANESTHESIA PROVIDERS S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD STE 100
KNOXVILLE TN
37932-1983
US

V. Phone/Fax

Practice location:
  • Phone: 865-293-5676
  • 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 Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK GORDON
Title or Position: PRESIDENT
Credential: MD
Phone: 865-293-5676