Basic Information
| Provider Information | |||||||||
| NPI: | 1003819194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED INFUSION SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCED INFUSION SYSTEMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 E DANA ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940411507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509616355 | ||||||||
| FaxNumber: | 6509695653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | CANERIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5026277100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | PHY 48702 | CA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 333600000X | PHY 48702 | CA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1003819194 | 05 | CA | MEDICAID | PHA406770 | 05 | CA | MEDICAID |