Basic Information
| Provider Information | |||||||||
| NPI: | 1144380213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MVB ANESTHESIA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 634 NE 20TH ST | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739423035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806517468 | ||||||||
| FaxNumber: | 5803384230 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739424438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803383113 | ||||||||
| FaxNumber: | 5803384230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | VANBEBBER | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | LYNNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5806517468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSN, CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 200100820A | 05 | OK | MEDICAID |