=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689659864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKHAVEN ANESTHESIA & PAIN MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2005
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1024 D A BIGLANE DR
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-826-5960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1547
-----------------------------------------------------
City | SEDALIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65302-1547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-826-5960
-----------------------------------------------------
Fax | 660-826-4852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBIN D NATIONS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 660-826-5960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------