MEDICARE: BLUE DOG ANESTHESIA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician		TX

General Provider Information

NPI Number	:	1033400213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE DOG ANESTHESIA PA

Provider Business Mailing Address
First Line	:	4100 INTERNATIONAL PLZ
Second Line	:	SUITE 600
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4820
Country	:	US
Telephone Number	:	817-334-0530
Fax Number	:	817-877-0350

Provider Business Practice Location Address
First Line	:	2929 AMHERST AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-7806
Country	:	US
Telephone Number	:	214-564-4972
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	THOMAS P. KENJARSKI
Credential	:	MD
Telephone Number	:	214-564-4972

Provider Enumeration Date	:	04/22/2011
Last Update Date	:	04/22/2011

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Directions to “BLUE DOG ANESTHESIA PA ” Practice Location

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