Provider Demographics
NPI:1750390274
Name:SANDUSKY BAY ANESTHESIA, LLC
Entity type:Organization
Organization Name:SANDUSKY BAY ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:S
Authorized Official - Last Name:WISNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:918-543-1020
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-0190
Mailing Address - Country:US
Mailing Address - Phone:918-543-1020
Mailing Address - Fax:918-543-2103
Practice Address - Street 1:1101 DECATUR ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3335
Practice Address - Country:US
Practice Address - Phone:918-543-1020
Practice Address - Fax:918-543-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
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
OH2312492Medicaid
OH9322121Medicare ID - Type Unspecified