Basic Information
| Provider Information | |||||||||
| NPI: | 1245314640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO CRNA SERVICES, INC. | ||||||||
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| OtherOrganizationName: | METRO ANESTHESIA AFFILIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 RIDGEVIEW DR STE 140-204 | ||||||||
| Address2: | |||||||||
| City: | ALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750135542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143907697 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 O CONNOR RIDGE BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750386573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179662762 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 05/08/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DELILLO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2143907697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DNP, CRNA, NSPM-C | ||||||||
| NPICertificationDate: | 05/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 006995701 | 05 | TX | MEDICAID |