Provider Demographics
NPI:1679555262
Name:LEAVENWORTH ANESTHESIA PA
Entity Type:Organization
Organization Name:LEAVENWORTH ANESTHESIA PA
Other - Org Name:MID-AMERICA ANESTHESIA CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:COVILLO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:913-680-0812
Mailing Address - Street 1:605 SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-1958
Mailing Address - Country:US
Mailing Address - Phone:913-680-0812
Mailing Address - Fax:913-680-1445
Practice Address - Street 1:605 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1958
Practice Address - Country:US
Practice Address - Phone:913-680-0812
Practice Address - Fax:913-680-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10811021OtherBCBS KANSAS CITY
KSCI9911OtherRR MEDICARE
10811021OtherPREFERRED HEALTH PROFESSI
KSC19910OtherRAILROAD MEDICARE
MODC6685OtherRR MEDICARE
KS004640OtherBCBS
MOCD7473OtherRAILROAD MEDICARE
MODC6685OtherRAILROAD MEDICARE
KSC19910OtherRAILROAD MEDICARE
10811021OtherPREFERRED HEALTH PROFESSI
=========001OtherTRICARE WPS
=========OtherCIGNA
=========OtherUNITED HEALTH CARE
=========OtherHUMANA
=========OtherHUMANA
MO=========OtherMERCY HEALTH PLANS OF MO
MOH810000BMedicare ID - Type Unspecified
MOW590000Medicare PIN