=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528956984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOONEVILLE ANESTHESIA SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2025
-----------------------------------------------------
Last Update Date | 06/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HOSPITAL ST
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38829-3354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-827-0492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1547
-----------------------------------------------------
City | SEDALIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65302-1547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-826-5960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MICHAEL CROUCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-826-5960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------