Provider Demographics
NPI:1912351933
Name:WINDBROOK ANESTHESIA LLC
Entity Type:Organization
Organization Name:WINDBROOK ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-733-4200
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10212 GOVERNOR LANE BLVD
Practice Address - Street 2:SUITE 1004
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-4086
Practice Address - Country:US
Practice Address - Phone:301-733-4200
Practice Address - Fax:301-223-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD517935Medicare PIN