Basic Information
| Provider Information | |||||||||
| NPI: | 1023201662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID FLORIDA ANESTHESIA ASSOCIATES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COASTAL PAIN SOLUTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR | ||||||||
| Address2: | SUITE 6633 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 SE OCEAN BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349963332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232115 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7723377676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH1211 | 01 | FL | RAILROAD MEDICARE | OTHER | 33576 | 01 | FL | BCBS OF FLORIDA | OTHER | 377780400 | 05 | FL | MEDICAID |