Basic Information
| Provider Information | |||||||||
| NPI: | 1912105172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA GULF TO BAY ANESTHESIOLOGY PAIN LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA GULF TO BAY PAIN MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 TAMPA GENERAL CIR | ||||||||
| Address2: | A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444396 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 S OREGON AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336061820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132532273 | ||||||||
| FaxNumber: | 8132532279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | MANGAR | ||||||||
| AuthorizedOfficialFirstName: | DEVANAND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8138444434 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 39348 | 01 | FL | BCBS | OTHER |