Provider Demographics
NPI:1366589590
Name:ANESTHESIA AND INTENSIVE CARE
Entity type:Organization
Organization Name:ANESTHESIA AND INTENSIVE CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:M
Authorized Official - Last Name:COLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-701-0156
Mailing Address - Street 1:51 DOGWOOD LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503
Mailing Address - Country:US
Mailing Address - Phone:903-701-0156
Mailing Address - Fax:903-793-7996
Practice Address - Street 1:1000 PINE STREET
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5100
Practice Address - Country:US
Practice Address - Phone:903-701-0156
Practice Address - Fax:903-793-7996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX090112602Medicaid
AR111373002Medicaid
AR111373002Medicaid
TXTXB119543Medicare PIN