MEDICARE: COLLIER ANESTHESIA PAIN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	94852	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1306899349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLIER ANESTHESIA PAIN LLC

Provider Business Mailing Address
First Line	:	PO BOX 638900
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-8900
Country	:	US
Telephone Number	:	239-939-7375
Fax Number	:	239-939-5105

Provider Business Practice Location Address
First Line	:	4035 EVANS AVE
Second Line	:	SUITE 1
City	:	FORT MYERS
State	:	FL
Zip	:	33901-9308
Country	:	US
Telephone Number	:	239-939-7375
Fax Number	:	239-939-5105

Authorized Official
Title or Position	:	MD
Name	:	WAYNE ISAACSON
Credential	:
Telephone Number	:	239-939-7375

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/21/2022

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