Provider Demographics
NPI:1891730321
Name:ANESTHESIOLOGY AND PAIN MANAGEMENT CONSULTANTS,LC
Entity Type:Organization
Organization Name:ANESTHESIOLOGY AND PAIN MANAGEMENT CONSULTANTS,LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:FOURNET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-614-9863
Mailing Address - Street 1:PO BOX 106002
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-6002
Mailing Address - Country:US
Mailing Address - Phone:317-614-9863
Mailing Address - Fax:844-876-0873
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:317-614-9863
Practice Address - Fax:844-876-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207LP2900X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24871OtherBLUE CROSS BLUE SHILED
FL376394300Medicaid
FLC11885OtherRAILROAD MEDICARE
FL=========OtherTRICARE
FLC11885OtherRAILROAD MEDICARE