Basic Information
| Provider Information | |||||||||
| NPI: | 1164939971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACHSIDE ANESTHESIA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 320281 | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329320281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 95 BULLDOG BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217299493 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2018 | ||||||||
| LastUpdateDate: | 01/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | BOGER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | MARGARET | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3217838926 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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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 | ARNP9164912 | 01 | FL | STATE DEPT HEALTH | OTHER |