Healthcare Provider Details

I. General information

NPI: 1487980397
Provider Name (Legal Business Name): FOUR RIVERS ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E 6TH ST
WASHINGTON MO
63090-3308
US

IV. Provider business mailing address

1 EAST LN
UNION MO
63084-1772
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-1766
  • Fax:
Mailing address:
  • Phone: 636-239-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR8N11
License Number StateMO

VIII. Authorized Official

Name: DR. PETER G WIENKE
Title or Position: PRESIDENT
Credential: MD
Phone: 636-239-1766