Provider Demographics
NPI:1871807206
Name:SHADOW ANESTHESIA SERVICES, LLC
Entity type:Organization
Organization Name:SHADOW ANESTHESIA SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:MS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:LASHMET
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:605-845-3502
Mailing Address - Street 1:403 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1813
Mailing Address - Country:US
Mailing Address - Phone:402-802-0246
Mailing Address - Fax:605-845-3502
Practice Address - Street 1:1401 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601
Practice Address - Country:US
Practice Address - Phone:605-845-8271
Practice Address - Fax:605-845-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100997261QR1300X, 282N00000X, 282NC0060X
KS55417282NC0060X, 282N00000X
SDCR000953282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD145111Medicaid
KS200304330Medicaid
KS11654543OtherCAQH
KS145111Medicare Oscar/Certification