Provider Demographics
NPI:1609252188
Name:RIVERCOAST ANESTHESIA, P.A.
Entity Type:Organization
Organization Name:RIVERCOAST ANESTHESIA, P.A.
Other - Org Name:RIVERCOAST PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DELANO
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-305-5987
Mailing Address - Street 1:1899 MURRELL RD STE 130
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3285
Mailing Address - Country:US
Mailing Address - Phone:321-305-5987
Mailing Address - Fax:321-338-2977
Practice Address - Street 1:1899 MURRELL RD STE 130
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3285
Practice Address - Country:US
Practice Address - Phone:321-305-5987
Practice Address - Fax:321-338-2977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11323261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain