Provider Demographics
NPI:1386776599
Name:ANESTHESIA CONSULTANTS OF PETTIS COUNTY, PC
Entity type:Organization
Organization Name:ANESTHESIA CONSULTANTS OF PETTIS COUNTY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-447-7220
Mailing Address - Street 1:PO BOX 411881
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1881
Mailing Address - Country:US
Mailing Address - Phone:888-447-7220
Mailing Address - Fax:336-884-1643
Practice Address - Street 1:1600 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:888-447-7220
Practice Address - Fax:336-884-1643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOK740000Medicare ID - Type Unspecified