Healthcare Provider Details

I. General information

NPI: 1760428361
Provider Name (Legal Business Name): SUNDANCE ANESTHESIA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 HARRIS PKWY
FORT WORTH TX
76132-4101
US

IV. Provider business mailing address

4200 S HULEN ST SUITE 425
FORT WORTH TX
76109-4908
US

V. Phone/Fax

Practice location:
  • Phone: 817-433-5000
  • Fax:
Mailing address:
  • Phone: 817-731-2875
  • Fax: 817-731-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ROBERT BRUCE LEITCH
Title or Position: PRESIDENT
Credential: MD
Phone: 817-731-2875