Provider Demographics
NPI:1710037130
Name:EDMISTON ANESTHESIA SERVICES PC
Entity Type:Organization
Organization Name:EDMISTON ANESTHESIA SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:EDMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-259-2525
Mailing Address - Street 1:PO BOX 15000
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-8901
Mailing Address - Country:US
Mailing Address - Phone:970-259-2525
Mailing Address - Fax:970-247-0421
Practice Address - Street 1:575 RIVERGATE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7487
Practice Address - Country:US
Practice Address - Phone:970-247-3537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ790403Medicaid
NMX9058Medicaid
CO37536079Medicaid
NMX9058Medicaid
CO050080875Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UT=========007Medicaid