MEDICARE: ESTES VALLEY ANESTHESIA LLC

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	CRA-2933	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C802029	OTHER	CO	MEDICARE ID FOR MARY BOLGEO
3	C188438	OTHER	CO	MEDICARE ID FOR JASON GOODWIN

Other Identifiers

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

General Provider Information

NPI Number	:	1679865372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESTES VALLEY ANESTHESIA LLC

Provider Business Mailing Address
First Line	:	850 NORTH LN
Second Line	:
City	:	ESTES PARK
State	:	CO
Zip	:	80517-9629
Country	:	US
Telephone Number	:	970-443-8855
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 NORTH LN
Second Line	:
City	:	ESTES PARK
State	:	CO
Zip	:	80517-9629
Country	:	US
Telephone Number	:	970-443-8855
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JASON GOODWIN
Credential	:	CRNA
Telephone Number	:	970-443-8855

Provider Enumeration Date	:	05/12/2011
Last Update Date	:	05/12/2011

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Directions to “ESTES VALLEY ANESTHESIA LLC ” Practice Location

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