=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336259571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN ANESTHESIA SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 09/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 419 W GRAY ST
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-7117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-809-4200
-----------------------------------------------------
Fax | 405-364-5379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 W GRAY ST
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-7117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-809-4200
-----------------------------------------------------
Fax | 405-364-5379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRIAN D MACKEY
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 405-501-4244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R0085277
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------