Provider Demographics
NPI:1073781167
Name:INDEPENDANT ANESTHESIOLOGISTS PSC
Entity Type:Organization
Organization Name:INDEPENDANT ANESTHESIOLOGISTS PSC
Other - Org Name:CRNA GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-341-7246
Mailing Address - Street 1:20 MEDICAL VILLAGE DRIVE
Mailing Address - Street 2:258
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:ONE MEDICAL VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPENDANT ANESTHESIOLOGISTS PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-12
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74905910Medicaid
KY0944Medicare PIN