Healthcare Provider Details

I. General information

NPI: 1871621623
Provider Name (Legal Business Name): CHETCO ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 CHETCO AVE
BROOKINGS OR
97415
US

IV. Provider business mailing address

PO BOX 8021
BROOKINGS OR
97415-0376
US

V. Phone/Fax

Practice location:
  • Phone: 503-650-4359
  • Fax: 503-650-6913
Mailing address:
  • Phone: 503-650-4359
  • Fax: 503-650-6913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateOR

VIII. Authorized Official

Name: JOHN RUSH
Title or Position: CEO
Credential: DO
Phone: 503-650-4359