Provider Demographics
NPI:1144241498
Name:TALLAHASSEE ANESTHESIOLOGY, P.A.
Entity Type:Organization
Organization Name:TALLAHASSEE ANESTHESIOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-567-2179
Mailing Address - Street 1:11460 N MERIDIAN ST
Mailing Address - Street 2:#110
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-4408
Mailing Address - Country:US
Mailing Address - Phone:317-567-2179
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:317-567-2179
Practice Address - Fax:317-567-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME6504207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259293200Medicaid
FLK1877Medicare PIN