=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104092089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOONEVILLE ANESTHESIA SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 05/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E COLLINS BLVD SUITE 110
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-2457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-913-8528
-----------------------------------------------------
Fax | 214-239-1660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 E COLLINS BLVD SUITE 110
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-2457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-913-8528
-----------------------------------------------------
Fax | 214-239-1660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | BRANDON JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 866-913-8528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------