Basic Information
| Provider Information | |||||||||
| NPI: | 1558381392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOLVERINE ANESTHESIA CONSULTANTS, INC. | ||||||||
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| OtherOrganizationName: | WOLVERINE ANESTHESIA CONSULTANTS, M.D., P.A. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617993552 | ||||||||
| FaxNumber: | 8652913224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 KUHL AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617993552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 12/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617993552 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 367500000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367H00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CI6774 | 01 | FL | MEDICARE - RRGA | OTHER | 255628600 | 05 | FL | MEDICAID | 38225 | 01 | FL | BCBS | OTHER |