Healthcare Provider Details

I. General information

NPI: 1902465560
Provider Name (Legal Business Name): SOUTHWEST ANESTHESIA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 S WALKER AVE BLDG C
OKLAHOMA CITY OK
73139-9404
US

IV. Provider business mailing address

15225 WESTERN VISTA DR
EDMOND OK
73013-9643
US

V. Phone/Fax

Practice location:
  • Phone: 887-093-1178
  • Fax: 405-606-8976
Mailing address:
  • Phone:
  • Fax:

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: DR. WESLEY A DICKSON
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 888-709-3117