| Entity Name: | FORT WALTON BEACH ANESTHESIA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 20 Dec 2002 (22 years ago) |
| Date of dissolution: | 22 Sep 2017 (7 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 22 Sep 2017 (7 years ago) |
| Document Number: | L02000034486 |
| FEI/EIN Number | 061670989 |
| Address: | 8201 UNIVERSITY PKWY, PENSACOLA, FL, 32514 |
| Mail Address: | 8201 UNIVERSITY PKWY, PENSACOLA, FL, 32514 |
| ZIP code: | 32514 |
| County: | Escambia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1538159652 | 2005-10-28 | 2008-06-24 | 8201 UNIVERSITY PKWY, PENSACOLA, FL, 325144904, US | 1000 MAR WALT DR, FORT WALTON BEACH, FL, 325476708, US | |||||||||||||||||||||||||||||||
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| Phone | +1 850-474-8688 |
| Fax | 8509692910 |
Authorized person
| Name | ANDY POPPLE |
| Role | EXECUTIVE DIRECTOR |
| Phone | 8504748000 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | RAILROAD MEDICARE |
| Number | CK6290 |
| Issuer | BLUE SHIELD |
| Number | 24572 |
| State | FL |
| Issuer | MEDICAID |
| Number | 266456900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| HUSTON GARY W | Agent | 125 W ROMANA ST, STE 800, PENSACOLA, FL, 32501 |
| Name | Role |
|---|---|
| MDV LLC | Manager |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2016-04-14 |
| ANNUAL REPORT | 2015-02-23 |
| ANNUAL REPORT | 2014-04-21 |
| ANNUAL REPORT | 2013-04-23 |
| ANNUAL REPORT | 2012-04-23 |
| ANNUAL REPORT | 2011-05-05 |
| ANNUAL REPORT | 2010-04-27 |
| ANNUAL REPORT | 2009-04-23 |
| ANNUAL REPORT | 2008-02-26 |
| ANNUAL REPORT | 2007-04-26 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
