Basic Information
| Provider Information | |||||||||
| NPI: | 1881709780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICTORIA ANESTHESIOLOGY ASSOC LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4897 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | NIELSEN | ||||||||
| AuthorizedOfficialFirstName: | BUDDY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3615732481 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 0841793-02 | 05 | TX | MEDICAID | 00N42X | 05 | TX | MEDICAID | CD3812 | 01 | TX | RR MEDICARE | OTHER | C31N | 01 | TX | BCBS TX CRNAS | OTHER | 00N42X | 01 | TX | BLUE CROSS GRP MD | OTHER |