MEDICARE: PAIN FREE ANESTHESIA PC

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	367500000X	Certified Registered Nurse Anesthetist	R0062898	OK

General Provider Information

NPI Number	:	1124221999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN FREE ANESTHESIA PC

Provider Business Mailing Address
First Line	:	5701 NE 107TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73151-9558
Country	:	US
Telephone Number	:	405-796-7080
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 NE 107TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73151-9558
Country	:	US
Telephone Number	:	405-769-7080
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TODD RUSSELL HENDERSON
Credential	:	CRNA
Telephone Number	:	405-312-4145

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	08/29/2007

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