Basic Information
| Provider Information | |||||||||
| NPI: | 1679848220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORT LAVACA ANESTHESIA GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742976 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753742976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142544672 | ||||||||
| FaxNumber: | 9033744711 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 N VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779793025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615526713 | ||||||||
| FaxNumber: | 9035520362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2012 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2142544672 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.