Provider Demographics
NPI:1548272990
Name:PEDIATRIC ANESTHESIA PA
Entity type:Organization
Organization Name:PEDIATRIC ANESTHESIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-490-6100
Mailing Address - Street 1:204 37TH AVE N
Mailing Address - Street 2:STE 322
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1416
Mailing Address - Country:US
Mailing Address - Phone:813-490-6100
Mailing Address - Fax:813-490-6105
Practice Address - Street 1:10080 BALAYE RUN DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7902
Practice Address - Country:US
Practice Address - Phone:813-490-6100
Practice Address - Fax:813-490-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74845OtherBCBS
FL273454OtherWELLCARE
FL74845OtherBCBS