Healthcare Provider Details

I. General information

NPI: 1487696142
Provider Name (Legal Business Name): PHYSICIANS ANESTHESIA OF SWEETWATER COUNTY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 COLLEGE DR
ROCK SPRINGS WY
82901-5868
US

IV. Provider business mailing address

744 W MICHIGAN AVE
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 307-362-3711
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: EDMUND BOESE
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: M.D.
Phone: 307-362-3711