=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801161898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-AMERICA ANESTHESIA SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2012
-----------------------------------------------------
Last Update Date | 03/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 W NIFONG BLVD BLDG 6 #130
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-5615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-875-8838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1316 OLD HIGHWAY 63 S SUITE 102
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-6092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-875-8838
-----------------------------------------------------
Fax | 573-875-8589
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK COHEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 573-875-8838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------