Healthcare Provider Details

I. General information

NPI: 1891730321
Provider Name (Legal Business Name): ANESTHESIOLOGY AND PAIN MANAGEMENT CONSULTANTS,LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

PO BOX 106002
ATLANTA GA
30348-6002
US

V. Phone/Fax

Practice location:
  • Phone: 317-614-9863
  • Fax: 844-876-0873
Mailing address:
  • Phone: 317-614-9863
  • Fax: 844-876-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateFL

VIII. Authorized Official

Name: KEITH FOURNET
Title or Position: PRESIDENT
Credential: MD
Phone: 317-614-9863