Provider Demographics
NPI:1225347396
Name:BLAYLOCK ANESTHESIA GROUP
Entity Type:Organization
Organization Name:BLAYLOCK ANESTHESIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:WINNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:940-683-0300
Mailing Address - Street 1:1905 DOCTORS HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-2260
Mailing Address - Country:US
Mailing Address - Phone:940-683-0300
Mailing Address - Fax:
Practice Address - Street 1:1905 DOCTORS HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2260
Practice Address - Country:US
Practice Address - Phone:940-683-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227712171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX007073201Medicaid
TX00C69AMedicare PIN