Basic Information
| Provider Information | |||||||||
| NPI: | 1871531293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELAND ANESTHESIOLOGY GROUP INC | ||||||||
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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: | 701 W PLYMOUTH AVE | ||||||||
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| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327203236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076670444 | ||||||||
| FaxNumber: | 4076674338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | DELGADO | ||||||||
| AuthorizedOfficialFirstName: | EDMUNDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER OF DELAND ANESTHESIOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 4076670444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 274046000 | 05 | FL | MEDICAID | 94844 | 01 | FL | BCBS | OTHER |