Basic Information
| Provider Information | |||||||||
| NPI: | 1184889842 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX ANESTHESIA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11286 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729171286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852555 | ||||||||
| FaxNumber: | 4797853555 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 WE KNIGHT DR | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797096702 | ||||||||
| FaxNumber: | 4797096730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 05/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | TEETER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4797852555 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 |
No ID Information.