Basic Information
| Provider Information | |||||||||
| NPI: | 1174159834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISLAND PROFESSIONAL ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 MAKALIKA ST | ||||||||
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| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967205847 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 WAIANUENUE AVE | ||||||||
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| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967202089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089323000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2020 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | REIDY | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8959078765 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.