Basic Information
Provider Information | |||||||||
NPI: | 1619571361 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FDHS ANESTHESIA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 735641 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753735641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8883373509 | ||||||||
FaxNumber: | 9413283997 | ||||||||
Practice Location | |||||||||
Address1: | 2089 HAWTHORNE ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | SARASOTA | ||||||||
State: | FL | ||||||||
PostalCode: | 342392301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9419521145 | ||||||||
FaxNumber: | 8666658561 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/24/2020 | ||||||||
LastUpdateDate: | 03/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KREGER | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2059994132 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   | 367500000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.