Provider Demographics
NPI:1942337001
Name:ORAL ANESTHESIA GROUP INC
Entity Type:Organization
Organization Name:ORAL ANESTHESIA GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA,CASC
Authorized Official - Phone:417-447-2482
Mailing Address - Street 1:1103 E MONTCLAIR ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5076
Mailing Address - Country:US
Mailing Address - Phone:417-447-2482
Mailing Address - Fax:
Practice Address - Street 1:1103 E MONTCLAIR ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5076
Practice Address - Country:US
Practice Address - Phone:417-447-2482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507601508Medicaid
MO507601508Medicaid