Provider Demographics
NPI:1336612795
Name:MIDWEST ALLIANCE SERVICES LLC
Entity Type:Organization
Organization Name:MIDWEST ALLIANCE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BOOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:507-206-1680
Mailing Address - Street 1:5261 SANDY LOOP
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501
Mailing Address - Country:US
Mailing Address - Phone:507-206-1680
Mailing Address - Fax:
Practice Address - Street 1:800 N. 1ST ST.
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403
Practice Address - Country:US
Practice Address - Phone:715-261-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty