Healthcare Provider Details

I. General information

NPI: 1578814422
Provider Name (Legal Business Name): GRUBE ANESTHESIA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 KOHLER MEMORIAL DR STE 101
SHEBOYGAN WI
53081-3100
US

IV. Provider business mailing address

4293 BECKER RD
AUBURNDALE WI
54412-9530
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-8142
  • Fax:
Mailing address:
  • Phone: 715-652-3219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number35223
License Number StateWI

VIII. Authorized Official

Name: DOUGLAS M GRUBE
Title or Position: OWNER
Credential: CRNA
Phone: 715-652-3219