Provider Demographics
NPI:1073546792
Name:MTC ANESTHESIA, LLP
Entity Type:Organization
Organization Name:MTC ANESTHESIA, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:214-320-3975
Mailing Address - Street 1:5027 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-3329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:214-265-2810
Practice Address - Fax:214-265-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C91SOtherBLUE CROSS BLUE SHIELD
TX00W215Medicare ID - Type UnspecifiedMTC ANESTHESIA GROUP