1659477461 NPI number — BAYSHORE ANESTHESIA P A

Table of content: (NPI 1659477461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659477461 NPI number — BAYSHORE ANESTHESIA P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYSHORE ANESTHESIA P A
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:
1659477461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7419
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-7419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-867-8898
Provider Business Mailing Address Fax Number:
352-732-6282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2190 HIGHWAY 85 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-1045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-867-8898
Provider Business Practice Location Address Fax Number:
352-732-6282
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROADERICK
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
MD/PRESIDENT
Authorized Official Telephone Number:
352-867-8898

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  ME69348 , 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: 28253 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 379870400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com