1275534059 NPI number — GULF COAST ANESTHESIA LLC

Table of content: (NPI 1275534059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275534059 NPI number — GULF COAST ANESTHESIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF COAST 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:
1275534059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
767 AIRPORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32405-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-747-0400
Provider Business Mailing Address Fax Number:
850-913-9744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
767 AIRPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-747-0400
Provider Business Practice Location Address Fax Number:
850-913-9744
Provider Enumeration Date:
08/03/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELZAWAHRY
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-747-0400

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  L04000049725 , 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: 74982 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".