Provider Demographics
NPI:1396067070
Name:NEW AGE BIOMEDICAL SERVICES LLC
Entity type:Organization
Organization Name:NEW AGE BIOMEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-494-0048
Mailing Address - Street 1:PO BOX 116422
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 N DAVIS HWY
Practice Address - Street 2:STE 253
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2337
Practice Address - Country:US
Practice Address - Phone:850-494-0048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty