Provider Demographics
NPI:1184603201
Name:BUENA VISTA ANESTHESIA ASSOCIATES PLC
Entity type:Organization
Organization Name:BUENA VISTA ANESTHESIA ASSOCIATES PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MAXINE
Authorized Official - Last Name:KRAUTH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:573-686-5550
Mailing Address - Street 1:209 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5831
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:573-686-5550
Practice Address - Street 1:1525 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:573-686-2139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100514367500000X
MO148752367500000X
IAD040615367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0160879Medicaid
P00252415OtherTRAV RR
40130OtherBCBS
40130OtherBCBS