Provider Demographics
NPI:1174671614
Name:BRANDON JOHNSON BOONEVILLE ANESTHESIA SERVICES
Entity Type:Organization
Organization Name:BRANDON JOHNSON BOONEVILLE ANESTHESIA SERVICES
Other - Org Name:BOONEVILLE ANESTHESIA SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-235-5588
Mailing Address - Street 1:PO BOX 868148
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75086-8148
Mailing Address - Country:US
Mailing Address - Phone:469-235-5588
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3354
Practice Address - Country:US
Practice Address - Phone:469-235-5588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty