Healthcare Provider Details

I. General information

NPI: 1013313733
Provider Name (Legal Business Name): LAKEWOOD AMBULATORY ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 POINTE WEST BLVD STE 101
BRADENTON FL
34209-5525
US

IV. Provider business mailing address

PO BOX 25095
TAMPA FL
33622-5095
US

V. Phone/Fax

Practice location:
  • Phone: 941-360-1566
  • Fax: 941-358-9818
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: BARRY L. SEVERS
Title or Position: MEMBER MANAGER
Credential: MD
Phone: 941-745-6829