Provider Demographics
NPI:1427329150
Name:KEVIN J GREENWOOD P A
Entity type:Organization
Organization Name:KEVIN J GREENWOOD P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREENWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:727-376-9097
Mailing Address - Street 1:9540 VENTURI DR
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4645
Mailing Address - Country:US
Mailing Address - Phone:727-376-9097
Mailing Address - Fax:813-433-5540
Practice Address - Street 1:9540 VENTURI DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4645
Practice Address - Country:US
Practice Address - Phone:727-376-9097
Practice Address - Fax:813-433-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAN1633502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0174OtherMEDICARE PTAN