Provider Demographics
NPI:1609959808
Name:REGIONAL ANESTHESIA SVS LC
Entity Type:Organization
Organization Name:REGIONAL ANESTHESIA SVS LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:STREETMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:918-649-3426
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0727
Mailing Address - Country:US
Mailing Address - Phone:918-649-3426
Mailing Address - Fax:
Practice Address - Street 1:105 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4433
Practice Address - Country:US
Practice Address - Phone:918-649-3426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23472367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK363399510002OtherOK BLUE CROSS BLUE SHILED
OK74953A001OtherCHAMPUS
OK445484005001OtherOK BLUE CROSS BLUE SHILED
AR91578OtherARK BLUE CROSS BLUE SHILE
OK1465231Medicare ID - Type UnspecifiedUMWA
OK363399510002OtherOK BLUE CROSS BLUE SHILED