Basic Information
| Provider Information | |||||||||
| NPI: | 1467820100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COBALT BLUE ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX T | ||||||||
| Address2: | |||||||||
| City: | WAXAHACHIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751681107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726687460 | ||||||||
| FaxNumber: | 9726687467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1324 BROWN ST | ||||||||
| Address2: | #600 | ||||||||
| City: | WAXAHACHIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751651421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729374000 | ||||||||
| FaxNumber: | 9726687467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2015 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9726687460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.