Basic Information
| Provider Information | |||||||||
| NPI: | 1194786376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF ANESTHESIOLOGY-CORPUS CHRISTI | ||||||||
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| OtherOrganizationName: | ANESTHESIOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616945445 | ||||||||
| FaxNumber: | 3616945449 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616945445 | ||||||||
| FaxNumber: | 3616945449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIZZO | ||||||||
| AuthorizedOfficialFirstName: | CARLENE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | ANESTHESIA SERVICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3616944449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UTMB FACULTY GROUP PRACTICE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | HV49 | 01 | TX | BLUE CROSS/BLUE SHIELD | OTHER | 1003788860 | 05 | KS | MEDICAID | 112837302 | 05 | TX | MEDICAID |