=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518442607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UP ANESTHESIA SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2018
-----------------------------------------------------
Last Update Date | 12/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 3RD AVE W STE 170
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34205-8632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-782-5434
-----------------------------------------------------
Fax | 941-782-5438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4754 E STATE ROAD 64
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34208-9058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-337-3509
-----------------------------------------------------
Fax | 941-328-3997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | SEAN CASTELLUCCI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 888-337-3509
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------