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General NPI Number Information
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NPI Number | 1487980397
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Entity Type | Organization
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Legal Business Name | FOUR RIVERS ANESTHESIA
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Dates
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Enumeration Date | 10/28/2009
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Last Update Date | 10/28/2009
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Provider Practice Location Address
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Address Line | 1111 E 6TH ST
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City | WASHINGTON
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State | MO
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Zip | 63090-3308
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Country | US
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Telephone | 636-239-1766
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Fax |
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Provider Business Mailing Address
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Address Line | 1 EAST LN
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City | UNION
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State | MO
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Zip | 63084-1772
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Country | US
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Telephone | 636-239-1766
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PETER G WIENKE
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Credential | MD
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Telephone | 636-239-1766
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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 | R8N11
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License Number State | MO
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