Provider Demographics
NPI:1508387382
Name:ANESTHESIA INTENSIVE CARE LLC
Entity Type:Organization
Organization Name:ANESTHESIA INTENSIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:563-324-8160
Mailing Address - Street 1:PO BOX 2490
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52809-2490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2459
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Single Specialty