Provider Demographics
NPI:1275789414
Name:LAKESHORE ANESTHESIA, INC.
Entity Type:Organization
Organization Name:LAKESHORE ANESTHESIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENNON
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-723-9598
Mailing Address - Street 1:PO BOX 24620 #CL 600017
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33416-4620
Mailing Address - Country:US
Mailing Address - Phone:561-723-9598
Mailing Address - Fax:
Practice Address - Street 1:39200 HOOKER HIGHWAY
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430
Practice Address - Country:US
Practice Address - Phone:561-996-6571
Practice Address - Fax:561-996-2898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81129207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259768300Medicaid
FLH26903Medicare UPIN
FL51668Medicare PIN