Provider Demographics
NPI:1679848220
Name:PORT LAVACA ANESTHESIA GROUP LLC
Entity Type:Organization
Organization Name:PORT LAVACA ANESTHESIA GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-254-4672
Mailing Address - Street 1:PO BOX 742976
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-2976
Mailing Address - Country:US
Mailing Address - Phone:214-254-4672
Mailing Address - Fax:903-374-4711
Practice Address - Street 1:815 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-3025
Practice Address - Country:US
Practice Address - Phone:361-552-6713
Practice Address - Fax:903-552-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty