Provider Demographics
NPI:1124135546
Name:GRAND FORKS ANESTHESIA SERVICES PC
Entity type:Organization
Organization Name:GRAND FORKS ANESTHESIA SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:218-779-9048
Mailing Address - Street 1:3366 DESERT STAR LN
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5823
Mailing Address - Country:US
Mailing Address - Phone:701-746-7441
Mailing Address - Fax:701-746-7447
Practice Address - Street 1:3035 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4040
Practice Address - Country:US
Practice Address - Phone:701-775-3151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22456367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN765D7GROtherBCBS
CJ6769OtherRR MEDICARE
MN010322500Medicaid
ND05522001OtherBCBS
ND11925Medicaid
ND05522001OtherBCBS