Provider Demographics
NPI:1356819791
Name:BREAKWATER ANESTHESIA, INC.
Entity Type:Organization
Organization Name:BREAKWATER ANESTHESIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BEVILACQUA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:617-922-5655
Mailing Address - Street 1:7 ELWELL ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-2905
Mailing Address - Country:US
Mailing Address - Phone:617-922-5655
Mailing Address - Fax:
Practice Address - Street 1:900 CUMMINGS CTR STE 117T
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6183
Practice Address - Country:US
Practice Address - Phone:617-922-5655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-04
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992048870OtherNPI - JACOB BEVILACQUA
1679916142OtherNPI - PATRICK KEATING