Provider Demographics
NPI:1013525112
Name:SOUTH SHORE ANESTHESIA STAFFING
Entity Type:Organization
Organization Name:SOUTH SHORE ANESTHESIA STAFFING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SKELLENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CRNA
Authorized Official - Phone:906-399-3611
Mailing Address - Street 1:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:818-340-9988
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE STE 235
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5406
Practice Address - Country:US
Practice Address - Phone:906-361-4901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-15
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty