Basic Information
| Provider Information | |||||||||
| NPI: | 1912012642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE HARBOR ANESTHESIA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20042 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337420042 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3637 4TH ST N | ||||||||
| Address2: | STE 400 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337041355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | TORTORICE | ||||||||
| AuthorizedOfficialFirstName: | BERNARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 7278232188 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 94973 | 01 | FL | BCBS | OTHER | DD6596 | 01 | FL | RR MEDICARE | OTHER |