MEDICARE: STEPHEN MALMBERG CRNA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	RN 681192	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G0468	OTHER	FL	BLUE SHIELD

General Provider Information

NPI Number	:	1760588206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN MALMBERG CRNA

Provider Business Mailing Address
First Line	:	5824 BEE RIDGE RD
Second Line	:	PMB 312
City	:	SARASOTA
State	:	FL
Zip	:	34233-5065
Country	:	US
Telephone Number	:	941-929-7620
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 NOKOMIS AVE S
Second Line	:	STE 200
City	:	VENICE
State	:	FL
Zip	:	34285-3209
Country	:	US
Telephone Number	:	941-485-0295
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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