MEDICARE: JEANINE MARIE LAGODA CRNA

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	367500000X	Certified Registered Nurse Anesthetist	615226	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01095287	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	8164UB	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1962400069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANINE MARIE LAGODA CRNA

Provider Business Mailing Address
First Line	:	2411 FOUNTAIN VIEW DR.
Second Line	:	STE. 200
City	:	HOUSTON
State	:	TX
Zip	:	77057-4817
Country	:	US
Telephone Number	:	713-620-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2411 FOUNTAIN VIEW DR.
Second Line	:	STE. 200
City	:	HOUSTON
State	:	TX
Zip	:	77057-4817
Country	:	US
Telephone Number	:	713-620-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	12/04/2012

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