Provider Demographics
NPI:1578798468
Name:PEDIATRIC RADIOANESTHESIA SUPPLY
Entity Type:Organization
Organization Name:PEDIATRIC RADIOANESTHESIA SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:O
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PA
Authorized Official - Phone:972-840-2804
Mailing Address - Street 1:3200 BROADWAY BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1573
Mailing Address - Country:US
Mailing Address - Phone:972-840-2804
Mailing Address - Fax:972-840-2884
Practice Address - Street 1:3200 BROADWAY BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75403
Practice Address - Country:US
Practice Address - Phone:972-840-2804
Practice Address - Fax:972-840-2884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5299332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies