Basic Information
| Provider Information | |||||||||
| NPI: | 1699813808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUELCH ANESTHESIA SERVICES, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | STE. 120 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791719 | ||||||||
| FaxNumber: | 9157716558 | ||||||||
| Practice Location | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | STE. 120 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791719 | ||||||||
| FaxNumber: | 9157716558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | QUELCH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9157791716 | ||||||||
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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 | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 00C64R | 01 | TX | BCBS | OTHER | 152783001 | 05 | TX | MEDICAID |