Provider Demographics
NPI:1235177361
Name:PACELINE ANESTHESIA SERVICE PC
Entity Type:Organization
Organization Name:PACELINE ANESTHESIA SERVICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:WORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:417-437-2712
Mailing Address - Street 1:5333 S CLOVERDALE LN
Mailing Address - Street 2:
Mailing Address - City:BATTLEFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65619-9691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5333 S CLOVERDALE LN
Practice Address - Street 2:
Practice Address - City:BATTLEFIELD
Practice Address - State:MO
Practice Address - Zip Code:65619-9691
Practice Address - Country:US
Practice Address - Phone:417-437-2712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111469367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509327003Medicaid
MO000014022Medicare PIN
MO509327003Medicaid