Provider Demographics
NPI:1205841186
Name:OLYMPIA ANESTHESIA, PLC
Entity Type:Organization
Organization Name:OLYMPIA ANESTHESIA, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-809-9464
Mailing Address - Street 1:PO BOX 21050
Mailing Address - Street 2:DEPT OA2015
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121
Mailing Address - Country:US
Mailing Address - Phone:918-809-9464
Mailing Address - Fax:
Practice Address - Street 1:6901 S OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1843
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200070080AMedicaid
611105300OtherDEPT OF LABOR
OK200070080AMedicaid
500522134Medicare PIN
OKDD9850Medicare PIN