Healthcare Provider Details

I. General information

NPI: 1265710115
Provider Name (Legal Business Name): LIBERTY ANESTHESIA MANAGEMENT PROFESSIONALS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 W. PLANO PKWY
PLANO TX
75093-4640
US

IV. Provider business mailing address

P.O. BOX 2626
FORT WORTH TX
76113-2626
US

V. Phone/Fax

Practice location:
  • Phone: 972-620-1700
  • Fax:
Mailing address:
  • Phone: 817-294-7444
  • Fax: 817-294-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number633146
License Number StateTX

VIII. Authorized Official

Name: CECE PANNELL
Title or Position: OFF MGR
Credential:
Phone: 817-294-7444