Basic Information
| Provider Information | |||||||||
| NPI: | 1013350875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TREASURE COAST ANESTHESIA GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616232052 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 SE HOSPITAL AVE | ||||||||
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| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722875200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2013 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616232000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 008811301 | 05 | FL | MEDICAID | 008811300 | 05 | FL | MEDICAID | 004F4 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 008811302 | 05 | FL | MEDICAID |