Provider Demographics
NPI:1770016503
Name:ANTEBELLUM ANESTHESIA, LLC
Entity Type:Organization
Organization Name:ANTEBELLUM ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DNAP, CRNA
Authorized Official - Phone:850-896-8799
Mailing Address - Street 1:653 W 23RD ST
Mailing Address - Street 2:#284
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3922
Mailing Address - Country:US
Mailing Address - Phone:850-896-8799
Mailing Address - Fax:
Practice Address - Street 1:202 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4454
Practice Address - Country:US
Practice Address - Phone:850-896-8799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-08
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9216040367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000503500Medicaid
1235261595OtherNPI
FLBH925ZMedicare UPIN