Basic Information
| Provider Information | |||||||||
| NPI: | 1790008324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. ANTHONYS ANESTHESIA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1075 KINGWOOD DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773393010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813588114 | ||||||||
| FaxNumber: | 2813580609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2807 LITTLE YORK RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770933405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136977777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | BOIN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2813480426 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0045TG | 01 | TX | BCBS DOCTORS GROUP | OTHER | 00C65X | 01 | TX | BCBS CRNAS GROUP | OTHER |