Basic Information
| Provider Information | |||||||||
| NPI: | 1740295120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPHTHALMIC ANESTHESIA SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30585 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871900585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052437754 | ||||||||
| FaxNumber: | 5052434804 | ||||||||
| Practice Location | |||||||||
| Address1: | 11005 SPAIN RD NE STE 17 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871111871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052437729 | ||||||||
| FaxNumber: | 5052434804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | HEISCH | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5052437754 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 89174836 | 05 | NM | MEDICAID |