Provider Demographics
NPI:1649251745
Name:COLLIER ANESTHESIA PA
Entity type:Organization
Organization Name:COLLIER ANESTHESIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-261-1158
Mailing Address - Street 1:PO BOX 674391
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4391
Mailing Address - Country:US
Mailing Address - Phone:239-261-1158
Mailing Address - Fax:239-261-4232
Practice Address - Street 1:1336 CREEKSIDE BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108
Practice Address - Country:US
Practice Address - Phone:239-261-1158
Practice Address - Fax:239-261-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39347OtherBLUE CROSS/BLUE SHIELD
FL371075100Medicaid
FL39347Medicare PIN