MEDICARE: EXECUTIVE ANESTHESIA INC.

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	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1457821324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE ANESTHESIA INC.

Provider Business Mailing Address
First Line	:	4532 W KENNEDY BLVD STE 134
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-2042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4532 W KENNEDY BLVD STE 134
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-2042
Country	:	US
Telephone Number	:	731-624-9595
Fax Number	:

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	STEVEN MARVIN SWAN
Credential	:
Telephone Number	:	813-340-4224

Provider Enumeration Date	:	12/04/2018
Last Update Date	:	03/07/2019

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