MEDICARE: SOUTH LAKE ANESTHESIA SERVICES, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	207L00000X	Anesthesiology Physician
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	FL
3	367500000X	Certified Registered Nurse Anesthetist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DA3883	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	45233	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1346255056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LAKE ANESTHESIA SERVICES, P.A.

Provider Business Mailing Address
First Line	:	PO BOX 100024
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30348-0024
Country	:	US
Telephone Number	:	352-243-9114
Fax Number	:	352-243-7822

Provider Business Practice Location Address
First Line	:	1900 DON WICKHAM DR
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-1979
Country	:	US
Telephone Number	:	352-243-9114
Fax Number	:	352-243-7822

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID S GHIVIZZANI
Credential	:	M.D.
Telephone Number	:	352-243-9114

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	12/09/2011

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1518932052 — JEROME STURM M.D.
Practice Location Address:

1900 DON WICKHAM DR , SUITE 110
CLERMONT, FL
34711-1979

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1669411997 — DR. JULIE HOLLAND MD
Practice Location Address:

1900 DON WICKHAM DR
CLERMONT, FL
34711-1979

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1649297078 — DR. KERRY LENNARD NEALL M.D.
Practice Location Address:

1900 DON WICKHAM DR , EMERGENCY DEPARTMENT
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34711-1979

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Directions to “SOUTH LAKE ANESTHESIA SERVICES, P.A. ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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