Basic Information
| Provider Information | |||||||||
| NPI: | 1801130588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERMAN ANESTHESIOLOGY GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 291 SOUTHHALL LN | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076670444 | ||||||||
| FaxNumber: | 4076674338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522533765 | ||||||||
| FaxNumber: | 3522533487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 11/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | OLIN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4076670444 | ||||||||
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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 | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP3000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | BCBS | OTHER | PENDING | 05 | FL | MEDICAID |