Basic Information
| Provider Information | |||||||||
| NPI: | 1659477461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYSHORE ANESTHESIA P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7419 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328917419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Practice Location | |||||||||
| Address1: | 2190 HIGHWAY 85 N | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325781045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | BROADERICK | ||||||||
| AuthorizedOfficialFirstName: | ARTHUR | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3528678898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | ME69348 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 28253 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 379870400 | 05 | FL | MEDICAID |