Healthcare Provider Details

I. General information

NPI: 1295688976
Provider Name (Legal Business Name): PORTLAND ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PORTLAND AVE
OKLAHOMA CITY OK
73112-2074
US

IV. Provider business mailing address

PO BOX 1547
SEDALIA MO
65302-1547
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-5960
  • Fax: 660-826-4852
Mailing address:
  • Phone: 660-826-5960
  • Fax: 660-826-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CROUCH
Title or Position: MANAGER
Credential:
Phone: 660-826-5960