Provider Demographics
NPI:1730300054
Name:JSC ANESTHESIA PC
Entity Type:Organization
Organization Name:JSC ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-525-2090
Mailing Address - Street 1:650 ADDISON AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5444
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:1601 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6313
Practice Address - Country:US
Practice Address - Phone:208-525-2090
Practice Address - Fax:208-525-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN22808367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8K776OtherBLUE CROSS OF IDAHO
ID8K776OtherBLUE CROSS OF IDAHO