=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417609405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REM ANESTHESIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2022
-----------------------------------------------------
Last Update Date | 03/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6302 MONROVIA ST
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66216-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-845-7502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15600 ALHAMBRA ST
-----------------------------------------------------
City | OVERLAND PARK
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66224-8734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMBER TIBERIO
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 913-808-0956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------