Provider Demographics
NPI:1639813447
Name:SPORTSORTHO ANESTHESIA
Entity Type:Organization
Organization Name:SPORTSORTHO ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDBOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-465-1091
Mailing Address - Street 1:610 KAMALI DRIVE
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-0233
Mailing Address - Country:US
Mailing Address - Phone:956-465-1091
Mailing Address - Fax:866-575-6395
Practice Address - Street 1:610 KAMALI DRIVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-0233
Practice Address - Country:US
Practice Address - Phone:956-465-1091
Practice Address - Fax:866-575-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty