Basic Information
| Provider Information | |||||||||
| NPI: | 1205841186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLYMPIA ANESTHESIA, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21050 | ||||||||
| Address2: | DEPT OA2015 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188099464 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6901 S OLYMPIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741321843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | WENGER | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9188099464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/20/2021 | ||||||||
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 | 200070080A | 05 | OK | MEDICAID | 611105300 | 01 | DEPT OF LABOR | OTHER |