MEDICARE: BLUEBONNET ANESTHESIA PLLC

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

General Provider Information

NPI Number	:	1952843088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET ANESTHESIA PLLC

Provider Business Mailing Address
First Line	:	PO BOX 112
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47308-0112
Country	:	US
Telephone Number	:	765-284-0493
Fax Number	:

Provider Business Practice Location Address
First Line	:	5204 SILVER LAKE DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-7564
Country	:	US
Telephone Number	:	979-216-7249
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	SURESH VALLOPPILLIL
Credential	:
Telephone Number	:	979-216-7249

Provider Enumeration Date	:	11/07/2016
Last Update Date	:	11/07/2016

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