Provider Demographics
NPI:1104818079
Name:FAYETTE ANESTHESIA SERVICES, INC.
Entity type:Organization
Organization Name:FAYETTE ANESTHESIA SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SWENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:740-606-0630
Mailing Address - Street 1:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-0153
Mailing Address - Country:US
Mailing Address - Phone:717-263-5562
Mailing Address - Fax:717-263-1566
Practice Address - Street 1:1150 W LOCUST ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2572
Practice Address - Country:US
Practice Address - Phone:937-383-0088
Practice Address - Fax:937-382-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2017-01-12
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
OH2299123Medicaid
OH9318691Medicare PIN
OH2647434Medicaid
OHFA9318692Medicare ID - Type UnspecifiedGRP NUMBER@HDH
OHFA9318691Medicare ID - Type UnspecifiedGRP NUMBER@FCMH