1629038450 NPI number — OKLAHOMA CITY ANESTHESIA, LLC

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 1629038450 NPI number — OKLAHOMA CITY ANESTHESIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA CITY ANESTHESIA, LLC
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:
1629038450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 NW 63RD ST.
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-296-3270
Provider Business Mailing Address Fax Number:
918-720-0270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11200 N. PORTLAND AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-296-3270
Provider Business Practice Location Address Fax Number:
918-720-0270
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAYLESS
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
TANNER
Authorized Official Title or Position:
OWNER/MANAGING MEMBER
Authorized Official Telephone Number:
405-250-4221

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100748950A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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