Provider Demographics
NPI:1487980397
Name:FOUR RIVERS ANESTHESIA
Entity type:Organization
Organization Name:FOUR RIVERS ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:WIENKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-239-1766
Mailing Address - Street 1:1 EAST LN
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MO
Mailing Address - Zip Code:63084-1772
Mailing Address - Country:US
Mailing Address - Phone:636-239-1766
Mailing Address - Fax:
Practice Address - Street 1:1111 E 6TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3308
Practice Address - Country:US
Practice Address - Phone:636-239-1766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N11207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty