Provider Demographics
NPI:1902093230
Name:MOON BAY ANESTHESIA, PC
Entity Type:Organization
Organization Name:MOON BAY ANESTHESIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEEDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-473-0181
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:21 SE 3RD ST
Practice Address - Street 2:500
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708-1412
Practice Address - Country:US
Practice Address - Phone:812-473-0181
Practice Address - Fax:812-473-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043831A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN220050Medicare PIN