MEDICARE: EDEN 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	207L00000X	Anesthesiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CB9923	OTHER	MI	MEDICARE RAILROAD GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050A111210	OTHER	MI	BCBS-DR
2	430A111200	OTHER	MI	BCBS-GROUP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356370241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN ANESTHESIA SERVICES INC.

Provider Business Mailing Address
First Line	:	31 N SAINT JOSEPH AVE
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2207
Country	:	US
Telephone Number	:	269-687-1424
Fax Number	:	269-687-1472

Provider Business Practice Location Address
First Line	:	31 N SAINT JOSEPH AVE
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2207
Country	:	US
Telephone Number	:	269-687-1424
Fax Number	:	269-687-1472

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARY LOU STROCK
Credential	:
Telephone Number	:	269-983-8195

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	04/19/2018

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Directions to “EDEN ANESTHESIA SERVICES INC. ” Practice Location

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