Provider Demographics
NPI:1215006028
Name:RUBY DOME ANESTHESIA LLC
Entity Type:Organization
Organization Name:RUBY DOME ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:775-778-6634
Mailing Address - Street 1:PO BOX 2723
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89803
Mailing Address - Country:US
Mailing Address - Phone:775-778-6634
Mailing Address - Fax:775-778-6634
Practice Address - Street 1:2001 ERRECART BLVD
Practice Address - Street 2:NORTHEASTERN NEVADA REGIONAL HOSPITAL
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801
Practice Address - Country:US
Practice Address - Phone:775-738-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCH8833OtherMEDICARE PALMETTO GBA
NVCH8833OtherMEDICARE PALMETTO GBA