Healthcare Provider Details

I. General information

NPI: 1174159834
Provider Name (Legal Business Name): ISLAND PROFESSIONAL ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 WAIANUENUE AVE
HILO HI
96720-2089
US

IV. Provider business mailing address

605 MAKALIKA ST
HILO HI
96720-5847
US

V. Phone/Fax

Practice location:
  • Phone: 808-932-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEPHEN REIDY
Title or Position: OWNER
Credential:
Phone: 895-907-8765