Basic Information
| Provider Information | |||||||||
| NPI: | 1376592329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE ANESTHESIA ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 161785 | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175291920 | ||||||||
| FaxNumber: | 8173340235 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 12TH AVE | ||||||||
| Address2: | DEPT OF ANESTHESIOLOGY | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175291920 | ||||||||
| FaxNumber: | 8173340235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | BEARD | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLIENT LIASON | ||||||||
| AuthorizedOfficialTelephone: | 8173340530 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 161648401 | 05 | TX | MEDICAID |