MEDICARE: FAYETTE ANESTHESIA SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104818079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTE ANESTHESIA SERVICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 153
Second Line	:
City	:	GERMANTOWN
State	:	OH
Zip	:	45327-0153
Country	:	US
Telephone Number	:	717-263-5562
Fax Number	:	717-263-1566

Provider Business Practice Location Address
First Line	:	1150 W LOCUST ST
Second Line	:	SUITE 200
City	:	WILMINGTON
State	:	OH
Zip	:	45177-2572
Country	:	US
Telephone Number	:	937-383-0088
Fax Number	:	937-382-4654

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RICHARD SWENSEN
Credential	:	CRNA
Telephone Number	:	740-606-0630

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	01/12/2017

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