Provider Demographics
NPI:1659477461
Name:BAYSHORE ANESTHESIA P A
Entity Type:Organization
Organization Name:BAYSHORE ANESTHESIA P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BROADERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-867-8898
Mailing Address - Street 1:PO BOX 7419
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7419
Mailing Address - Country:US
Mailing Address - Phone:352-867-8898
Mailing Address - Fax:352-732-6282
Practice Address - Street 1:2190 HIGHWAY 85 N
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1045
Practice Address - Country:US
Practice Address - Phone:352-867-8898
Practice Address - Fax:352-732-6282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69348207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28253OtherBLUE CROSS BLUE SHIELD
FL379870400Medicaid
FL28253XMedicare ID - Type Unspecified