Provider Demographics
NPI:1679693782
Name:SUN COAST ANESTHESIA PA
Entity Type:Organization
Organization Name:SUN COAST ANESTHESIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRESLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-328-2093
Mailing Address - Street 1:PO BOX 6639
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-6639
Mailing Address - Country:US
Mailing Address - Phone:228-328-2093
Mailing Address - Fax:228-328-2079
Practice Address - Street 1:1720B MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2131
Practice Address - Country:US
Practice Address - Phone:228-702-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02179Medicare UPIN