Healthcare Provider Details

I. General information

NPI: 1851324800
Provider Name (Legal Business Name): PALM BAY ANESTHESIA ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MALABAR RD NE
PALM BAY FL
32907-2506
US

IV. Provider business mailing address

804 SCOTT NIXON MEMORIAL DR
AUGUSTA GA
30907-2464
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-8025
  • Fax:
Mailing address:
  • Phone: 706-650-0705
  • Fax: 706-650-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MARK VANDENBOSCH
Title or Position: OWNER
Credential: MD
Phone: 321-784-3700