MEDICARE: SOUTHLAKE PREMIER 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	207LP2900X	Pain Medicine (Anesthesiology) Physician
2	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1710524095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAKE PREMIER ANESTHESIA, PLLC

Provider Business Mailing Address
First Line	:	2600 E SOUTHLAKE BLVD STE 120
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-8045
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 N TARRANT PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8611
Country	:	US
Telephone Number	:	210-996-6363
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	EVERLY MILLER
Credential	:
Telephone Number	:	210-996-6363

Provider Enumeration Date	:	12/05/2019
Last Update Date	:	12/05/2019

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