Provider Demographics
NPI:1184904252
Name:ANISTA CORPORATION
Entity type:Organization
Organization Name:ANISTA CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILL
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-855-4555
Mailing Address - Street 1:10718 COUNTRYWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1733
Mailing Address - Country:US
Mailing Address - Phone:813-855-4000
Mailing Address - Fax:
Practice Address - Street 1:10718 COUNTRYWAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1733
Practice Address - Country:US
Practice Address - Phone:813-855-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty