Provider Demographics
NPI:1952328767
Name:MITCHELL ANESTHESIA PC
Entity Type:Organization
Organization Name:MITCHELL ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN ERDEWYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-995-2000
Mailing Address - Street 1:PO BOX 5126
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5126
Mailing Address - Country:US
Mailing Address - Phone:605-335-1952
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:525 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2966
Practice Address - Country:US
Practice Address - Phone:605-995-2000
Practice Address - Fax:605-995-5645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0250207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0003527OtherBCBS - GROUP
NE10025039000Medicaid
SDS3527Medicare PIN
SDCG6479Medicare ID - Type UnspecifiedRAILROAD