Provider Demographics
NPI:1033390059
Name:KEOKUK ANETHESIA ASSOCIATES
Entity Type:Organization
Organization Name:KEOKUK ANETHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAGADAMBA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTAMNENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-524-7123
Mailing Address - Street 1:1512 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-4028
Mailing Address - Country:US
Mailing Address - Phone:319-524-7123
Mailing Address - Fax:319-524-7123
Practice Address - Street 1:1512 MORGAN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-4028
Practice Address - Country:US
Practice Address - Phone:319-524-7123
Practice Address - Fax:319-524-7123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25219207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI8636Medicare PIN