Provider Demographics
NPI:1174612857
Name:MID TEX ANESTHESIA ASSOC
Entity type:Organization
Organization Name:MID TEX ANESTHESIA ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-776-0266
Mailing Address - Street 1:PO BOX 224137
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-4137
Mailing Address - Country:US
Mailing Address - Phone:254-776-0266
Mailing Address - Fax:254-776-2511
Practice Address - Street 1:405 LONDONDERRY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7920
Practice Address - Country:US
Practice Address - Phone:254-776-0266
Practice Address - Fax:254-776-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00EZ73OtherBLUE CROSS BLUE SHIELD
TX098220902Medicaid
TX00EZ73Medicare PIN