Provider Demographics
NPI:1194060624
Name:PROACTIVE ANESTHESIA MANAGEMENT LLC
Entity type:Organization
Organization Name:PROACTIVE ANESTHESIA MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-274-3310
Mailing Address - Street 1:320 1ST ST N
Mailing Address - Street 2:SUITE 603
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6944
Mailing Address - Country:US
Mailing Address - Phone:904-274-3310
Mailing Address - Fax:
Practice Address - Street 1:320 1ST ST N
Practice Address - Street 2:SUITE 603
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6944
Practice Address - Country:US
Practice Address - Phone:904-274-3310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty