Basic Information
| Provider Information | |||||||||
| NPI: | 1326085101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAPSOKAVATHIS | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | ELENI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOUMANDRAKIS | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | ELENI | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1268 SOUTHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480093082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137891678 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 COLUMBIA DR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444434 | ||||||||
| FaxNumber: | 8138444467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 05/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP2630332 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1437268026 | 01 | MI | MEDICARE PTAN | OTHER | 1811044878 | 01 | MI | MEDICARE GROUP NPI | OTHER | G3801 | 01 | FL | FL BCBS PROVIDER # | OTHER | 307098100 | 05 | FL | MEDICAID |