=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346500949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOREMOST ANESTHESIA STAFFING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2012
-----------------------------------------------------
Last Update Date | 01/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 368 NE FRANKLIN ST
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-3088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-215-7015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1665 KINGSLEY AVE SUITE 105
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-215-7015
-----------------------------------------------------
Fax | 904-215-7715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. DEEVID OSCAR MILLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 904-215-7015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------