Basic Information
Provider Information | |||||||||
NPI: | 1295776243 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOBILE ANESTHESIA ASSOCIATES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ANESTHESIA ASSOCIATES OF FLORIDA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 161745 | ||||||||
Address2: |   | ||||||||
City: | ALTAMONTE SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 327161745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888514642 | ||||||||
FaxNumber: | 2403423837 | ||||||||
Practice Location | |||||||||
Address1: | 325 AVENUE B NW | ||||||||
Address2: |   | ||||||||
City: | WINTER HAVEN | ||||||||
State: | FL | ||||||||
PostalCode: | 338814651 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8632914000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2006 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ADKINS | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8284240869 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 377066400 | 05 | FL |   | MEDICAID | 33005 | 01 | FL | BS FL | OTHER |