Provider Demographics
NPI:1063552511
Name:WISE COUNTY ANESTHESIA ASSOCIATES
Entity type:Organization
Organization Name:WISE COUNTY ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:940-627-3033
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-4652
Mailing Address - Country:US
Mailing Address - Phone:940-627-3033
Mailing Address - Fax:940-627-3572
Practice Address - Street 1:609 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-4652
Practice Address - Country:US
Practice Address - Phone:940-627-5921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDOH9805174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDOH9805OtherLICENSE NUMBER
TX3536HMOtherBLUE CROSS GROUP ID NUMBE
TXF07927Medicare UPIN
TX3536HMOtherBLUE CROSS GROUP ID NUMBE