Basic Information
| Provider Information | |||||||||
| NPI: | 1235298241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA OF ENID LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 W WILLOW RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737032511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802423003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 S MONROE ST | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737017211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802332300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | MATLI | ||||||||
| AuthorizedOfficialFirstName: | MONTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5802423003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANESTHESIOLOGY MANAGEMENT INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/08/2021 | ||||||||
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 | 1235298241 | 05 | OK | MEDICAID |