=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811059876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKY MOUNTAIN ANESTHESIA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 PROFESSIONAL PLZ SUITE 100
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-656-8442
-----------------------------------------------------
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 | ANTHONY HARWARD
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 208-525-2090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | N-32894
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------