Provider Demographics
NPI:1306035944
Name:METROPLEX ADVENTIST HOSPITAL CRNA INC
Entity Type:Organization
Organization Name:METROPLEX ADVENTIST HOSPITAL CRNA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-519-8165
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76540-0938
Mailing Address - Country:US
Mailing Address - Phone:254-634-6999
Mailing Address - Fax:254-200-4099
Practice Address - Street 1:2201 S CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4110
Practice Address - Country:US
Practice Address - Phone:254-519-8165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193418401Medicaid
TX00C91VOtherBCBS OF TEXAS
TX00C91VOtherBCBS OF TEXAS