Provider Demographics
NPI:1053699736
Name:MOBILE ANESTHESIOLOGISTS OF MISSOURI, LLC
Entity type:Organization
Organization Name:MOBILE ANESTHESIOLOGISTS OF MISSOURI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:GERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-276-2667
Mailing Address - Street 1:8420 W BRYN MAWR AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3479
Mailing Address - Country:US
Mailing Address - Phone:773-355-5300
Mailing Address - Fax:
Practice Address - Street 1:8420 W BRYN MAWR AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3479
Practice Address - Country:US
Practice Address - Phone:773-355-5300
Practice Address - Fax:773-714-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011012170207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ726903Medicaid
AZH73500Medicare UPIN
AZ71818Medicare PIN