Provider Demographics
NPI:1295752137
Name:LEWIS AND CLARK ANESTHESIA, PROF. LLC
Entity type:Organization
Organization Name:LEWIS AND CLARK ANESTHESIA, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-664-5050
Mailing Address - Street 1:307 WALNUT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-4361
Mailing Address - Country:US
Mailing Address - Phone:605-664-5050
Mailing Address - Fax:605-664-5051
Practice Address - Street 1:2601 FOX RUN PKWY
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-5341
Practice Address - Country:US
Practice Address - Phone:605-665-5100
Practice Address - Fax:605-665-5200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0040262OtherWELLMARK BCBS
SDDA2864OtherRAILROAD
SD9202984OtherDAKOTACARE
SDDA2864OtherRAILROAD
SD=========Medicaid
NE=========00Medicaid