Provider Demographics
NPI:1144511452
Name:GROVE CITY ANESTHESIA LLC
Entity type:Organization
Organization Name:GROVE CITY ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-313-0175
Mailing Address - Street 1:PO BOX 2193
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2193
Mailing Address - Country:US
Mailing Address - Phone:208-552-8777
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:1485 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1667
Practice Address - Country:US
Practice Address - Phone:208-785-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty