Provider Demographics
NPI:1790723377
Name:GILA ANESTHESIOLOGY SERVICES, PC
Entity Type:Organization
Organization Name:GILA ANESTHESIOLOGY SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:S
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-284-0493
Mailing Address - Street 1:1801 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-1953
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:765-213-3240
Practice Address - Street 1:1313 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7251
Practice Address - Country:US
Practice Address - Phone:505-538-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM7400047Medicaid
NM89080874Medicaid
NM30409861Medicaid