Provider Demographics
NPI:1902931199
Name:LEGACY ANESTHESIA SERVICES, PLLC
Entity Type:Organization
Organization Name:LEGACY ANESTHESIA SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:612-735-1469
Mailing Address - Street 1:1575 20TH ST NW
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021
Mailing Address - Country:US
Mailing Address - Phone:612-735-1469
Mailing Address - Fax:
Practice Address - Street 1:1575 20TH ST NW
Practice Address - Street 2:SUITE 203
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:612-735-1469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNPP000Medicare UPIN