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General NPI Number Information
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NPI Number | 1720039977
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ANESTHESIA, P.C.
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 700 E BEARDSLEY AVE STE 209
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City | ELKHART
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State | IN
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Zip | 46514-3371
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Country | US
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Telephone | 574-522-9922
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Fax | 574-522-9926
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Provider Business Mailing Address
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Address Line | PO BOX 2147
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City | ELKHART
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State | IN
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Zip | 46515-2147
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Country | US
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Telephone | 574-522-9922
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Fax | 574-522-9926
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Authorized Official
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Title or Position | CEO
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Name | MR. SETH CLAXTON
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Credential | CRNA
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Telephone | 574-522-9922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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