=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639128267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLE KEYS ANESTHESIA ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 03/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 OVERSEAS HWY FISHERMEN'S HOSPITAL ANESTHESIA DEPT
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-289-6407
-----------------------------------------------------
Fax | 305-289-6417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 PIRATES CV
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-743-0222
-----------------------------------------------------
Fax | 305-743-0114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | HARLAN ERIC PETTIT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 305-743-0222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------