1063552511 NPI number — WISE COUNTY ANESTHESIA ASSOCIATES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063552511 NPI number — WISE COUNTY ANESTHESIA ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISE COUNTY ANESTHESIA ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063552511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76234-4652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-627-3033
Provider Business Mailing Address Fax Number:
940-627-3572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76234-4652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-627-5921
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAYLOCK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER ANESTHESIOLOGIST
Authorized Official Telephone Number:
940-627-3033

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  DOH9805 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DOH9805 . This is a "LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 3536HM . This is a "BLUE CROSS GROUP ID NUMBE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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