Healthcare Provider Details

I. General information

NPI: 1972073930
Provider Name (Legal Business Name): VIGILANT ANESTHESIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 E SHEA BLVD STE 230
PHOENIX AZ
85028-4259
US

IV. Provider business mailing address

4100 INTERNATIONAL PLZ STE 600
FORT WORTH TX
76109-4823
US

V. Phone/Fax

Practice location:
  • Phone: 602-513-8133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN MIELCAREK
Title or Position: OWNER
Credential: MD
Phone: 602-790-7190