Basic Information
| Provider Information | |||||||||
| NPI: | 1003875469 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST ANESTHESIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26168 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731260168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478585 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 NW EXPRESSWAY | ||||||||
| Address2: | 2ND FLOOR, DEPARTMENT OF ANESTHESIOLOGY | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059512815 | ||||||||
| FaxNumber: | 4059512495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | GAWEY | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4059475557 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100743880A | 05 | OK | MEDICAID | 175289900 | 01 | DOL GRP NUMBER | OTHER |