Provider Demographics
NPI:1790066363
Name:J R ANESTHESIA PROF LLC
Entity Type:Organization
Organization Name:J R ANESTHESIA PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:605-381-5104
Mailing Address - Street 1:2014 HARNEY DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-5113
Mailing Address - Country:US
Mailing Address - Phone:605-381-5104
Mailing Address - Fax:
Practice Address - Street 1:3615 5TH ST
Practice Address - Street 2:100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6014
Practice Address - Country:US
Practice Address - Phone:605-343-6714
Practice Address - Fax:605-343-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty