=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992188510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANSFIELD ANESTHESIA CONSULTANTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2015
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 REGENCY PKWY
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-7823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-405-9591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 CHERRY ST SUITE 2000
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-6803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED AGENT
-----------------------------------------------------
Name | STEPHEN L POLOZOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-405-9591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------