=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093958035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEARBORN DREAMS ANESTHESIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2009
-----------------------------------------------------
Last Update Date | 05/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5515 GULF DR STE B
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-843-9200
-----------------------------------------------------
Fax | 727-843-9400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6094 14TH ST W STE 128
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34207-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | SREENIVAS P. VANGARA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 727-843-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------