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General NPI Number Information
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NPI Number | 1104358464
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Entity Type | Organization
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Legal Business Name | SUMMIT ANESTHESIA LLC
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 04/20/2017
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Provider Practice Location Address
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Address Line | 2620 EAGAN WOODS DRIVE SUITE 300
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City | EAGAN
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State | MN
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Zip | 55121-1466
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Country | US
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Telephone | 651-730-3532
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Fax |
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Provider Business Mailing Address
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Address Line | 710 COMMERCE DR SUITE 200
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City | WOODBURY
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State | MN
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Zip | 55125-4919
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | ADAM BERRY
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Credential |
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Telephone | 651-968-5333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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