1952756728 NPI number — FPRA ANESTHESIA SERVICES LLC

Table of content: (NPI 1952756728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952756728 NPI number — FPRA ANESTHESIA SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FPRA 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:
1952756728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6094 14TH ST W
Provider Second Line Business Mailing Address:
#177
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34207-4104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-360-1566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1693 LEE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32789-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-287-4300
Provider Business Practice Location Address Fax Number:
407-982-8048
Provider Enumeration Date:
04/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SAJAN
Authorized Official First Name:
CHERIAN
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
MD/MEMBER
Authorized Official Telephone Number:
941-360-1566

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115245700 . 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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