MEDICARE: LIFEGUARD ANESTHESIA SERVICES LLC

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	:	1225557242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEGUARD ANESTHESIA SERVICES LLC

Provider Business Mailing Address
First Line	:	5406 E 110TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-7253
Country	:	US
Telephone Number	:	870-530-4660
Fax Number	:

Provider Business Practice Location Address
First Line	:	6310 E 102ND ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-7061
Country	:	US
Telephone Number	:	870-530-4660
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	TIMOTHY GIBSON
Credential	:	CRNA
Telephone Number	:	816-914-2583

Provider Enumeration Date	:	09/11/2017
Last Update Date	:	04/27/2020

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