Basic Information
Provider Information | |||||||||
NPI: | 1114270931 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENDO SEDATION LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 RESERVE ST STE 560 | ||||||||
Address2: |   | ||||||||
City: | SOUTHLAKE | ||||||||
State: | TX | ||||||||
PostalCode: | 760921607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174027526 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1001 SURREY LN | ||||||||
Address2: |   | ||||||||
City: | FLOWER MOUND | ||||||||
State: | TX | ||||||||
PostalCode: | 750224234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173373671 | ||||||||
FaxNumber: | 8179121887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2012 | ||||||||
LastUpdateDate: | 04/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHEELER | ||||||||
AuthorizedOfficialFirstName: | BRANDI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ANESTHESIA SUPPORT SERVICES | ||||||||
AuthorizedOfficialTelephone: | 8174027526 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   | 367500000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 00C74Y | 01 | TX | BCBS OF TEXAS | OTHER |