Provider Demographics
NPI:1003916107
Name:SOUTHEAST IOWA ANESTHESIA PLC
Entity Type:Organization
Organization Name:SOUTHEAST IOWA ANESTHESIA PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAINBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-1000
Mailing Address - Street 1:925 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 S GEAR AVE
Practice Address - Street 2:
Practice Address - City:W BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1679
Practice Address - Country:US
Practice Address - Phone:319-768-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI12899Medicare PIN