Healthcare Provider Details

I. General information

NPI: 1235373556
Provider Name (Legal Business Name): HIGHLANDS ANESTHESIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4364 WASHINGTON BLVD
OGDEN UT
84403-1866
US

IV. Provider business mailing address

6277 S 2225 E
OGDEN UT
84403-5301
US

V. Phone/Fax

Practice location:
  • Phone: 801-436-1637
  • Fax: 801-476-7002
Mailing address:
  • Phone: 801-920-0743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number380438-4406
License Number StateUT

VIII. Authorized Official

Name: MR. MICAH PATRICK KRONMILLER
Title or Position: PRESIDENT
Credential: CRNA
Phone: 801-920-0743