Basic Information
| Provider Information | |||||||||
| NPI: | 1285686337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA ATLANTIC ANESTHESIA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1960 NE 47TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333087708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544935005 | ||||||||
| FaxNumber: | 9549380957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 NE 47TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333087708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544935005 | ||||||||
| FaxNumber: | 9549380957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/30/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PALMA | ||||||||
| AuthorizedOfficialFirstName: | VALENTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9544935005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 21926 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 249141 | 01 | FL | AVMED | OTHER | 255051200 | 05 | FL | MEDICAID | CI3594 | 01 | FL | RAILROAD MEDICARE | OTHER |