Provider Demographics
NPI:1093826513
Name:BLACKFOOT ANESTHESIA SERVICES LLC
Entity type:Organization
Organization Name:BLACKFOOT ANESTHESIA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-523-4906
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0829
Mailing Address - Country:US
Mailing Address - Phone:208-523-4609
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-785-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2767OtherRAILROAD MEDICARE
ID1377365Medicare PIN