Provider Demographics
NPI:1376538140
Name:GREATER TULSA ANESTHESIOLOGISTS PLLC
Entity Type:Organization
Organization Name:GREATER TULSA ANESTHESIOLOGISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:DAUTENHAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-496-2400
Mailing Address - Street 1:DEPT 1654
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74182-0001
Mailing Address - Country:US
Mailing Address - Phone:405-947-8585
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:9423 E 95TH CT
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5805
Practice Address - Country:US
Practice Address - Phone:918-496-2400
Practice Address - Fax:405-948-6507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16586207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========74182A001OtherTRICARE STANDARD
OK=========001OtherBCBS
=========74182A001OtherTRICARE STANDARD
CG6933Medicare PIN