Provider Demographics
NPI:1558338400
Name:ARDMORE ANESTHESIA, INC.
Entity Type:Organization
Organization Name:ARDMORE ANESTHESIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-226-1251
Mailing Address - Street 1:PO BOX 1983
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402
Mailing Address - Country:US
Mailing Address - Phone:580-226-1251
Mailing Address - Fax:580-226-1254
Practice Address - Street 1:1012 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-226-1251
Practice Address - Fax:580-226-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744100AMedicare ID - Type Unspecified