Provider Demographics
NPI:1538159652
Name:FORT WALTON BEACH ANESTHESIA LLC
Entity type:Organization
Organization Name:FORT WALTON BEACH ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-474-8000
Mailing Address - Street 1:8201 UNIVERSITY PKWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-4904
Mailing Address - Country:US
Mailing Address - Phone:850-474-8688
Mailing Address - Fax:850-969-2910
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-474-8688
Practice Address - Fax:850-969-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK6290OtherRAILROAD MEDICARE
FL24572OtherBLUE SHIELD
FL266456900Medicaid
CK6290OtherRAILROAD MEDICARE
FL34572Medicare ID - Type Unspecified