MEDICARE: SAMUEL KYLE PENDLETON CRNA

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	674937	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	87985U	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1578676946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL KYLE PENDLETON CRNA

Provider Business Mailing Address
First Line	:	189 LAKE RIDGE RD
Second Line	:
City	:	TUSCOLA
State	:	TX
Zip	:	79562-3662
Country	:	US
Telephone Number	:	325-572-4097
Fax Number	:

Provider Business Practice Location Address
First Line	:	6250 US HIGHWAY 83
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79606-5215
Country	:	US
Telephone Number	:	325-428-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	11/01/2007

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