Provider Demographics
NPI:1639568058
Name:BLACK MOUNTAIN ANESTHESIA GROUP
Entity Type:Organization
Organization Name:BLACK MOUNTAIN ANESTHESIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:PRESCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MSNA
Authorized Official - Phone:918-850-5607
Mailing Address - Street 1:1255 LECUYER DR
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-8750
Practice Address - Country:US
Practice Address - Phone:970-824-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0205032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty