Provider Demographics
NPI:1134416373
Name:ENID SURGICAL ANESTHESIA LLC
Entity type:Organization
Organization Name:ENID SURGICAL ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:RENEE'
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-233-7171
Mailing Address - Street 1:1133 W WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2504
Mailing Address - Country:US
Mailing Address - Phone:580-233-7171
Mailing Address - Fax:580-233-6680
Practice Address - Street 1:1133 W WILLOW RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2504
Practice Address - Country:US
Practice Address - Phone:580-233-7171
Practice Address - Fax:580-233-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2665207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB6060OtherPTAN