1194456350 NPI number — BLUE CLOUD ANESTHESIA, LLC

Table of content: (NPI 1194456350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194456350 NPI number — BLUE CLOUD ANESTHESIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE CLOUD ANESTHESIA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194456350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
182 INDUSTRIAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ROCK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17327-8626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-759-4375
Provider Business Mailing Address Fax Number:
717-759-4336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10909 W LINEBAUGH AVE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33626-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-774-6003
Provider Business Practice Location Address Fax Number:
813-774-3255
Provider Enumeration Date:
06/20/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
DEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-340-1840

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114539501 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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