Provider Demographics
NPI:1194224303
Name:PREMIER ANESTHESIA SERVICES INC
Entity Type:Organization
Organization Name:PREMIER ANESTHESIA SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERUBE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:612-616-7731
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0570
Mailing Address - Country:US
Mailing Address - Phone:800-444-6110
Mailing Address - Fax:
Practice Address - Street 1:1575 20TH ST NW # 205A
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2930
Practice Address - Country:US
Practice Address - Phone:507-209-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-03
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1731367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1205223989Medicaid