Basic Information
| Provider Information | |||||||||
| NPI: | 1720011703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTHOUSE ANESTHESIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3012 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOYLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9048244990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 34970 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |