Provider Demographics
NPI:1821097361
Name:WEST BROAD ANESTHESIA, INC.
Entity Type:Organization
Organization Name:WEST BROAD ANESTHESIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURE/SIGNATORY
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-853-2389
Mailing Address - Street 1:PO BOX 715184
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-5184
Mailing Address - Country:US
Mailing Address - Phone:800-754-9764
Mailing Address - Fax:937-293-0960
Practice Address - Street 1:5100 W. BROAD STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1607
Practice Address - Country:US
Practice Address - Phone:614-853-2389
Practice Address - Fax:614-853-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005581B174400000X
207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0424062Medicaid
OH9913951Medicare ID - Type UnspecifiedGROUP MEDICARE
OHA15724Medicare UPIN
OH0424062Medicaid