Organization
PEDIATRIC ANESTHESIA PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GLENN VAUGHN MD (OWNER)
(813) 490-6100
Entity
Organization
Contact information
Practice address
10080 BALAYE RUN DR, TAMPA, FL 33619-7902
(813) 490-6100
(813) 490-6105
Mailing address
204 37TH AVE N, STE 322, ST PETERSBURG, FL 33704-1416
(813) 490-6100
(813) 490-6105
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
273454
WELLCARE
FL
01
—
74845
BCBS
FL
Enumeration date
08/13/2006
Last updated
08/22/2020
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