Healthcare Provider Details

I. General information

NPI: 1639168206
Provider Name (Legal Business Name): SURGICAL ANESTHESIA OF NORFOLK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W NORFOLK AVE
NORFOLK NE
68701-7701
US

IV. Provider business mailing address

PO BOX 1611 SURGICAL ANESTHESIA OF NORFOLK LLC
NORFOLK NE
68702-1611
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-7744
  • Fax: 308-382-7744
Mailing address:
  • Phone: 308-382-7744
  • Fax: 308-382-7744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY L RIVERA
Title or Position: OFFICE MANAGER
Credential:
Phone: 308-382-7744