Provider Demographics
NPI:1003312935
Name:GLACIER ANESTHESIA, PLLC
Entity Type:Organization
Organization Name:GLACIER ANESTHESIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDMS NPI COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LIZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-598-2801
Mailing Address - Street 1:4347 W NORTHWEST HWY STE 130 # 303
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-3866
Mailing Address - Country:US
Mailing Address - Phone:469-283-0561
Mailing Address - Fax:
Practice Address - Street 1:4347 W NORTHWEST HWY STE 130 # 303
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-3866
Practice Address - Country:US
Practice Address - Phone:469-283-0561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-31
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty