1063400075 NPI number — ANESTHESIA PROVIDERS OF EAST TEXAS, PA

Table of content: (NPI 1063400075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063400075 NPI number — ANESTHESIA PROVIDERS OF EAST TEXAS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANESTHESIA PROVIDERS OF EAST TEXAS, PA
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:
1063400075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALESTINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75802-1988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-723-2465
Provider Business Mailing Address Fax Number:
903-677-1694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 WILLOW CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
PALESTINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75801-4421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-723-2465
Provider Business Practice Location Address Fax Number:
903-677-1694
Provider Enumeration Date:
10/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-675-1186

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0069072-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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