Provider Demographics
NPI:1710026281
Name:SOUTHEAST ANESTHESIA ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEAST ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE ANESTHESIA
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:772-201-7510
Mailing Address - Street 1:PO BOX 8178
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-8178
Mailing Address - Country:US
Mailing Address - Phone:772-335-7005
Mailing Address - Fax:772-335-3394
Practice Address - Street 1:1715 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7520
Practice Address - Country:US
Practice Address - Phone:772-335-7005
Practice Address - Fax:772-335-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2018-11-02
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
FL303534400Medicaid
FLG9013Medicare ID - Type Unspecified