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General NPI Number Information
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NPI Number | 1033419791
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Entity Type | Organization
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Legal Business Name | MOONLIGHT ANESTHESIA, P.L.
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Dates
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Enumeration Date | 10/28/2010
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Last Update Date | 10/28/2010
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Provider Practice Location Address
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Address Line | 5238 MASON CORBIN CT SUITE 101
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City | FORT MYERS
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State | FL
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Zip | 33907-7738
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Country | US
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Telephone | 239-489-3166
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Fax | 239-481-3650
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Provider Business Mailing Address
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Address Line | PO BOX 07272
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City | FORT MYERS
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State | FL
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Zip | 33919-0272
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Country | US
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Telephone | 239-489-3166
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Fax | 239-481-3650
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | REBECCA MARANO
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Credential |
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Telephone | 239-489-3166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | ME97767
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License Number State | FL
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