Basic Information
| Provider Information | |||||||||
| NPI: | 1275789414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESHORE ANESTHESIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24620 #CL 600017 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334164620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617239598 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39200 HOOKER HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619966571 | ||||||||
| FaxNumber: | 5619962898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2008 | ||||||||
| LastUpdateDate: | 01/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | GLENNON | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617239598 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME81129 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 259768300 | 05 | FL | MEDICAID |