Basic Information
| Provider Information | |||||||||
| NPI: | 1265885453 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCARLET ANESTHESIA MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 674207 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729160521 | ||||||||
| FaxNumber: | 9722340212 | ||||||||
| Practice Location | |||||||||
| Address1: | 17051 DALLAS PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750017109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729160521 | ||||||||
| FaxNumber: | 9722340212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2016 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALLS | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9722344740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.