1942441753 NPI number — SPACE COAST ANESTHESIA SERVICES LLC

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 1942441753 NPI number — SPACE COAST ANESTHESIA SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST ANESTHESIA SERVICES 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:
1942441753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4919 MEMORIAL HWY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33634-7500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-610-0775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
595 N COURTENAY PKWY
Provider Second Line Business Practice Location Address:
103
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-569-6500
Provider Business Practice Location Address Fax Number:
813-569-6262
Provider Enumeration Date:
03/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
813-569-6500

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)





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