Healthcare Provider Details

I. General information

NPI: 1053870535
Provider Name (Legal Business Name): FORTIS ANESTHESIA MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12607 OLIVE BLVD
SAINT LOUIS MO
63141-6313
US

IV. Provider business mailing address

13236 N 7TH ST STE 4
PHOENIX AZ
85022-5343
US

V. Phone/Fax

Practice location:
  • Phone: 314-327-8070
  • 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

VIII. Authorized Official

Name: MISS EMILY LAWLER
Title or Position: OWNER
Credential:
Phone: 314-378-5422