MEDICARE: GLACIER ANESTHESIA, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1003312935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLACIER ANESTHESIA, PLLC

Provider Business Mailing Address
First Line	:	4347 W NORTHWEST HWY STE 130 # 303
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75220-3866
Country	:	US
Telephone Number	:	469-283-0561
Fax Number	:

Provider Business Practice Location Address
First Line	:	4347 W NORTHWEST HWY STE 130 # 303
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75220-3866
Country	:	US
Telephone Number	:	469-283-0561
Fax Number	:

Authorized Official
Title or Position	:	MDMS NPI COMPLIANCE OFFICER
Name	:	LIZETTE MORIN
Credential	:
Telephone Number	:	210-598-2801

Provider Enumeration Date	:	03/31/2018
Last Update Date	:	03/31/2018

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