=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578627246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLACIER ANESTHESIA SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 BUFFALO WAY
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-733-8677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 E 17TH ST
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-525-2090
-----------------------------------------------------
Fax | 208-525-2662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PHILIP C BLUM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-525-2090
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------