Healthcare Provider Details

I. General information

NPI: 1740228261
Provider Name (Legal Business Name): TYLER ANESTHESIA GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3414 GOLDEN RD
TYLER TX
75701-8336
US

IV. Provider business mailing address

PO BOX 140069
DALLAS TX
75214-0069
US

V. Phone/Fax

Practice location:
  • Phone: 903-597-0601
  • Fax:
Mailing address:
  • Phone: 214-522-0210
  • Fax: 214-522-0474

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. BOBBY GENE BENNETT JR.
Title or Position: OWNER
Credential: MD
Phone: 214-522-0210