Provider Demographics
NPI:1013973296
Name:WHITE RIVER ANESTHESIA ASSOCIATES, INC
Entity Type:Organization
Organization Name:WHITE RIVER ANESTHESIA ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:K
Authorized Official - Last Name:LUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-239-3392
Mailing Address - Street 1:PO BOX 842120
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-2120
Mailing Address - Country:US
Mailing Address - Phone:800-277-8151
Mailing Address - Fax:
Practice Address - Street 1:525 BRANSON LANDING BLVD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2052
Practice Address - Country:US
Practice Address - Phone:417-239-3392
Practice Address - Fax:417-239-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508765401Medicaid
OK200077410AMedicaid
MODC8634OtherRAILROAD
MO194111OtherMISSOURI BCBS
AR158909002Medicaid
MO194111OtherMISSOURI BCBS