1508103540 NPI number — AMELIA ANESTHESIA, PL

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 1508103540 NPI number — AMELIA ANESTHESIA, PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMELIA ANESTHESIA, PL
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:
1508103540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95429 BARNWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERNANDINA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32034-1698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-624-7088
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 S 18TH ST
Provider Second Line Business Practice Location Address:
ANESTHESIA DEPARTMENT
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-321-3533
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HOWINGTON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
904-556-1236

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: 105469000 . 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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