MEDICARE: BLUE CLOUD 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	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1790562379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE CLOUD ANESTHESIA, LLC

Provider Business Mailing Address
First Line	:	9709 LAKESIDE BLVD STE 350
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77381-1213
Country	:	US
Telephone Number	:	713-489-2198
Fax Number	:	713-489-2978

Provider Business Practice Location Address
First Line	:	12184 NATURAL BRIDGE RD # 90
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2017
Country	:	US
Telephone Number	:	314-391-4936
Fax Number	:	314-474-0191

Authorized Official
Title or Position	:	CEO
Name	:	DEVIN LARSEN
Credential	:
Telephone Number	:	208-340-1840

Provider Enumeration Date	:	09/08/2023
Last Update Date	:	01/27/2025

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