Provider Demographics
NPI:1790738854
Name:ST. JOSEPH VALLEY ANESTHESIA P.C.
Entity Type:Organization
Organization Name:ST. JOSEPH VALLEY ANESTHESIA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-233-3123
Mailing Address - Street 1:PO BOX 1742
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-1742
Mailing Address - Country:US
Mailing Address - Phone:574-233-3123
Mailing Address - Fax:574-233-3125
Practice Address - Street 1:5215 HOLY CROSS PARKWAY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:574-233-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200055220AMedicaid
IN169130Medicare ID - Type Unspecified