Basic Information
| Provider Information | |||||||||
| NPI: | 1972806925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13601 PRESTON RD | ||||||||
| Address2: | 1000W | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752404911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13601 PRESTON RD | ||||||||
| Address2: | 1000W | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752404911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2010 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9727155000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1972806925 | 05 | IL | MEDICAID |