1487887287 NPI number — ODYSSEY ANESTHESIA PA

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 1487887287 NPI number — ODYSSEY ANESTHESIA PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ODYSSEY ANESTHESIA 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:
1487887287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 INTERNATIONAL PLZ
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76109-4820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-668-7460
Provider Business Mailing Address Fax Number:
972-668-7467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 CAMINO LAGO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75039-3212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-668-7460
Provider Business Practice Location Address Fax Number:
972-668-7467
Provider Enumeration Date:
08/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VU
Authorized Official First Name:
HUNG
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-668-7460

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  K3517 , 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)





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