Basic Information
| Provider Information | |||||||||
| NPI: | 1851394993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENDRICK ANESTHESIA NETWORK | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 975503 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753975503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256704220 | ||||||||
| FaxNumber: | 3256728292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 PINE ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796012432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256704220 | ||||||||
| FaxNumber: | 3256728292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | POLK | ||||||||
| AuthorizedOfficialFirstName: | KARI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3256704393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 095027103 | 05 | TX | MEDICAID |