Provider Demographics
NPI:1013160126
Name:HASTY, FREDERICK EMERSON IV
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:EMERSON
Last Name:HASTY
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 816759
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-0759
Mailing Address - Country:US
Mailing Address - Phone:954-964-2450
Mailing Address - Fax:954-964-6084
Practice Address - Street 1:4300 ALTON RD
Practice Address - Street 2:SUITE 1401
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2948
Practice Address - Country:US
Practice Address - Phone:305-674-2742
Practice Address - Fax:954-964-6084
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL112976207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005548600Medicaid
FL84926OtherFLORIDA BLUE
FLGH340ZMedicare PIN