Basic Information
| Provider Information | |||||||||
| NPI: | 1891726394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESTIN ANESTHESIA, LLC | ||||||||
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| OtherOrganizationName: | DESTIN ANESTHESIA, PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 735771 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753735771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776835494 | ||||||||
| FaxNumber: | 4129375707 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325412909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506507606 | ||||||||
| FaxNumber: | 8503371698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | KREGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2059994132 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME61503 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 34180 | 01 | FL | BCBS | OTHER |