Healthcare Provider Details

I. General information

NPI: 1235579764
Provider Name (Legal Business Name): PARKVILLE ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 FONTANA LN STE 104
BALTIMORE MD
21237-3047
US

IV. Provider business mailing address

6094 14TH ST W STE 136
BRADENTON FL
34207-4104
US

V. Phone/Fax

Practice location:
  • Phone: 410-574-7776
  • Fax:
Mailing address:
  • Phone: 941-360-1566
  • Fax: 941-358-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: JOSEPH C. LIN
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 410-574-7776