Basic Information
Provider Information | |||||||||
NPI: | 1316202104 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MID-FLORIDA ANESTHESIA ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RESOLUTE PAIN SOLUTIONS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7100 W CAMINO REAL | ||||||||
Address2: | SUITE 301 | ||||||||
City: | BOCA RATON | ||||||||
State: | FL | ||||||||
PostalCode: | 334335510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5614652598 | ||||||||
FaxNumber: | 5614652599 | ||||||||
Practice Location | |||||||||
Address1: | 10244 S US HIGHWAY 1 | ||||||||
Address2: |   | ||||||||
City: | PORT ST LUCIE | ||||||||
State: | FL | ||||||||
PostalCode: | 349525615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7723377676 | ||||||||
FaxNumber: | 7723379034 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2012 | ||||||||
LastUpdateDate: | 08/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | JAY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5614652598 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RESOLUTE ANESTHESIA AND PAIN SOLUTIONS, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | FL | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.