Provider Demographics
NPI:1356370241
Name:EDEN ANESTHESIA SERVICES INC.
Entity type:Organization
Organization Name:EDEN ANESTHESIA SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:STROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8195
Mailing Address - Street 1:31 N SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2207
Mailing Address - Country:US
Mailing Address - Phone:269-687-1424
Mailing Address - Fax:269-687-1472
Practice Address - Street 1:31 N SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2207
Practice Address - Country:US
Practice Address - Phone:269-687-1424
Practice Address - Fax:269-687-1472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI050A111210OtherBCBS-DR
MI430A111200OtherBCBS-GROUP
MI1356370241Medicaid
MICB9923OtherMEDICARE RAILROAD GROUP
MI0M30910Medicare PIN
MI050A111210OtherBCBS-DR