Basic Information
| Provider Information | |||||||||
| NPI: | 1013160126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASTY | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | EMERSON | ||||||||
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| NameSuffix: | IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 816759 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330810759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549642450 | ||||||||
| FaxNumber: | 9549646084 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 ALTON RD | ||||||||
| Address2: | SUITE 1401 | ||||||||
| City: | MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331402948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056742742 | ||||||||
| FaxNumber: | 9549646084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 112976 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 005548600 | 05 | FL | MEDICAID | 84926 | 01 | FL | FLORIDA BLUE | OTHER |