Provider Demographics
NPI:1790562379
Name:BLUE CLOUD ANESTHESIA, LLC
Entity Type:Organization
Organization Name:BLUE CLOUD ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-340-1840
Mailing Address - Street 1:182 INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:17327-8626
Mailing Address - Country:US
Mailing Address - Phone:717-759-4375
Mailing Address - Fax:717-759-4336
Practice Address - Street 1:12184 NATURAL BRIDGE RD # 90
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2017
Practice Address - Country:US
Practice Address - Phone:314-391-4936
Practice Address - Fax:314-474-0191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE CLOUD ANESTHESIA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty