1225085442 NPI number — ANESTHESIA OF INDIAN RIVER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225085442 NPI number — ANESTHESIA OF INDIAN RIVER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANESTHESIA OF INDIAN RIVER INC
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:
1225085442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-8953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-867-8898
Provider Business Mailing Address Fax Number:
352-732-6282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 INDIAN RIVER BLVD
Provider Second Line Business Practice Location Address:
SUITE B-120
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-7103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-867-8898
Provider Business Practice Location Address Fax Number:
352-732-6282
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PORTELL
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTH REP
Authorized Official Telephone Number:
352-867-8898

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 253409600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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