Provider Demographics
NPI:1699754242
Name:MID-LAND ANESTHESIA ASSOCIATES
Entity type:Organization
Organization Name:MID-LAND ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:573-686-5550
Mailing Address - Street 1:RR 1 BOX 366
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63967-9724
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:
Practice Address - Street 1:219 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODA7268OtherRAILROAD MEDICARE
MO184883OtherMO BCBS