Provider Demographics
NPI:1104092089
Name:BOONEVILLE ANESTHESIA SERVICES LLC
Entity type:Organization
Organization Name:BOONEVILLE ANESTHESIA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
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:866-913-8528
Mailing Address - Street 1:1200 E COLLINS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2457
Mailing Address - Country:US
Mailing Address - Phone:866-913-8528
Mailing Address - Fax:214-239-1660
Practice Address - Street 1:1200 E COLLINS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2457
Practice Address - Country:US
Practice Address - Phone:866-913-8528
Practice Address - Fax:214-239-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty