Healthcare Provider Details

I. General information

NPI: 1609159516
Provider Name (Legal Business Name): MANUEL A. BERMUDEZ AA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2173 CENTERVILLE PL STE A
TALLAHASSEE FL
32308-8303
US

IV. Provider business mailing address

PO BOX 452198
SUNRISE FL
33345-2198
US

V. Phone/Fax

Practice location:
  • Phone: 850-385-0144
  • Fax:
Mailing address:
  • Phone: 954-838-2371
  • Fax: 954-851-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: