Basic Information
| Provider Information | |||||||||
| NPI: | 1376535773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS ANESTHESIA GROUP, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4916 OVERTON PLZ | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175291923 | ||||||||
| FaxNumber: | 8173340899 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGHLAND PARK VLG | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752052722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888543822 | ||||||||
| FaxNumber: | 9722330372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | FANG | ||||||||
| AuthorizedOfficialFirstName: | XIAO-EN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8888543822 | ||||||||
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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 | J0828 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 173914601 | 05 | TX | MEDICAID | 0017MU | 01 | TX | GROUP BLUE C BLUE S TX | OTHER |