1497737654 NPI number — PEACE RIVER ANESTHESIOLOGY ASSOCIATES PA

Table of content: (NPI 1497737654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497737654 NPI number — PEACE RIVER ANESTHESIOLOGY ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACE RIVER ANESTHESIOLOGY ASSOCIATES PA
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:
1497737654
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:
PO BOX 510626
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUNTA GORDA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33951-0626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-625-1951
Provider Business Mailing Address Fax Number:
941-625-3675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 E MARION AVE
Provider Second Line Business Practice Location Address:
CHARLOTTE REGIONAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
PUNTA GORDA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33950-3819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-637-2580
Provider Business Practice Location Address Fax Number:
641-637-2571
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
POLLIZZI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
941-625-1951

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 72852 . This is a "FL BLUE SHIELD GROUP PROV" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 064141300 . 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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