Unknown Individual – Certified Registered Nurse Anesthetist, NPI 1104801240

Unknown Individual is a healthcare provider. based in Bolivar, Missouri. specializing in Certified Registered Nurse Anesthetist. They hold a License No. 040110 (MO). The NPI Number for Unknown Individual is 1104801240

Main info

Organization
Inactive
45 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1104801240
Phone
(660) 826-5960
Address
1500 N OAKLAND AVE
Deactivation Date
16 October 2024

Doctor Profile

Medical School Name
OTHER
Secondary Phone
4173266000
Graduation Year
1981 (45 years ago)
PAC ID
9739265034
Group Practice PAC ID
2769574433
Professional Enrollment ID
I20080327000156
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience14
Completeness75
Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • Citizens Memorial Hospital, 1500, North Oakland Avenue, Bolivar, Polk County, Missouri, 65613, United States

    BOLIVAR, MO 656133011

    Phone: (660) 826-5960

    Fax: (660) 826-4852

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 65613)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 2769574433View full group profile
NameSpecialtyState
Emergency MedicineMO
P A T H O L O G YHI
-MO
Certified Registered Nurse Anesthetist (Crna)MO
P A T H O L O G YMN
Interventional Pain Management, AnesthesiologyNM
Emergency MedicineMO
Certified Registered Nurse Anesthetist (Crna)MO
Certified Registered Nurse Anesthetist (Crna)MO
Diagnostic RadiologyMO

Reviews

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Frequently asked questions

What federal number belongs to Unknown Individual?
The federal identifier for Unknown Individual is NPI 1104801240.
What is the next step if Unknown Individual is inactive?
Treat inactive as a signal to verify Unknown Individual through official channels.
What does Unknown Individual treat or focus on?
Patients typically see Unknown Individual under the specialty Certified Registered Nurse Anesthetist. Clinical services aligned with this taxonomy classification.
Where is Unknown Individual's primary listing?
We display Bolivar, Missouri because that is what the record indicates for Unknown Individual.
Is this NPI for an individual or an organization?
This listing corresponds to an Individual Provider.

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