Basic Information
| Provider Information | |||||||||
| NPI: | 1255319158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | B. R. A. ANESTHESIA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2241 F. M. 984 | ||||||||
| Address2: | |||||||||
| City: | ENNIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751190955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143990034 | ||||||||
| FaxNumber: | 9726465278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2241 F. M. 984 | ||||||||
| Address2: | |||||||||
| City: | ENNIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751190955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143990034 | ||||||||
| FaxNumber: | 9726465278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSEN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2143990034 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BSN, CRNA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 705290 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 888174 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 1762759-02 | 05 | TX | MEDICAID |