Healthcare Provider Details

I. General information

NPI: 1205880754
Provider Name (Legal Business Name): SOUTHCREST ANESTHESIA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 S 101ST EAST AVE
TULSA OK
74133-5716
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-2829
US

V. Phone/Fax

Practice location:
  • Phone: 918-294-4803
  • Fax:
Mailing address:
  • Phone: 615-465-7626
  • 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 Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MS. DEBBIE BREWER
Title or Position: DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 615-465-1626