Provider Demographics
NPI:1578814422
Name:GRUBE ANESTHESIA SERVICES, LLC
Entity Type:Organization
Organization Name:GRUBE ANESTHESIA SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRUBE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:715-652-3219
Mailing Address - Street 1:4293 BECKER RD
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:WI
Mailing Address - Zip Code:54412-9530
Mailing Address - Country:US
Mailing Address - Phone:715-652-3219
Mailing Address - Fax:
Practice Address - Street 1:2108 KOHLER MEMORIAL DR
Practice Address - Street 2:STE 101
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3100
Practice Address - Country:US
Practice Address - Phone:920-451-8142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35223367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty