Basic Information
| Provider Information | |||||||||
| NPI: | 1487887287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODYSSEY ANESTHESIA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 INTERNATIONAL PLZ | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726687460 | ||||||||
| FaxNumber: | 9726687467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 CAMINO LAGO | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750393212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726687460 | ||||||||
| FaxNumber: | 9726687467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 12/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | VU | ||||||||
| AuthorizedOfficialFirstName: | HUNG | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9726687460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | K3517 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.