Basic Information
| Provider Information | |||||||||
| NPI: | 1871802710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREDERICKSBURG ANESTHESIA CONSULTANTS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650802 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 132 E HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | ANGLETON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775154112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2010 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | HICKS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ CMO | ||||||||
| AuthorizedOfficialTelephone: | 9548382371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 219219703 | 05 | TX | MEDICAID |