Healthcare Provider Details

I. General information

NPI: 1669425641
Provider Name (Legal Business Name): ATLANTIC COAST ANESTHESIA ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SE TIFFANY AVE
PORT ST LUCIE FL
34952-7521
US

IV. Provider business mailing address

PO BOX 7520
PORT ST LUCIE FL
34985-7520
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-2471
  • Fax: 772-335-2497
Mailing address:
  • Phone: 772-335-2471
  • Fax: 772-335-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KEITH E INGRAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 772-335-2471