| Entity Name: | BAYSHORE ANESTHESIA, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 26 Apr 2000 (25 years ago) |
| Date of dissolution: | 25 Sep 2015 (9 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2015 (9 years ago) |
| Document Number: | P00000042033 |
| FEI/EIN Number | 593642299 |
| Address: | 2190 HIGHWAY 85 N, NICEVILLE, FL, 32578 |
| Mail Address: | 1013 CROOKED CREEK COVE, NICEVILLE, FL, 32578 |
| ZIP code: | 32578 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1659477461 | 2006-09-16 | 2011-08-09 | PO BOX 7419, ORLANDO, FL, 328917419, US | 2190 HIGHWAY 85 N, NICEVILLE, FL, 325781045, US | |||||||||||||||||||||||||||||||
|
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| Phone | +1 352-867-8898 |
| Fax | 3527326282 |
Authorized person
| Name | DR. ARTHUR PAUL BROADERICK |
| Role | MD/PRESIDENT |
| Phone | 3528678898 |
Taxonomy
| Taxonomy Code | 207LP2900X - Pain Medicine (Anesthesiology) Physician |
| License Number | ME69348 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 28253 |
| State | FL |
| Issuer | MEDICAID |
| Number | 379870400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BROADERICK ARTHUR P | Agent | 1013 CROOKED CREEK, NICEVILLE, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| BROADERICK ARTHUR P | Director | 1013 CROOKED CREEK COVE, NICEVILLE, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| BROADERICK KATHLEEN E | Manager | 1013 CROOKED CREEK COVE, NICEVILLE, FL, 32578 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2011-04-07 | 2190 HIGHWAY 85 N, NICEVILLE, FL 32578 | No data |
| REGISTERED AGENT NAME CHANGED | 2011-04-07 | BROADERICK, ARTHUR P | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2009-07-17 | 1013 CROOKED CREEK, NICEVILLE, FL 32578 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2008-05-27 | 2190 HIGHWAY 85 N, NICEVILLE, FL 32578 | No data |
| CANCEL ADM DISS/REV | 2006-02-03 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2014-04-19 |
| ANNUAL REPORT | 2013-04-30 |
| ANNUAL REPORT | 2012-05-04 |
| ANNUAL REPORT | 2011-04-07 |
| ANNUAL REPORT | 2010-03-03 |
| ANNUAL REPORT | 2009-07-17 |
| ANNUAL REPORT | 2008-05-27 |
| ANNUAL REPORT | 2007-02-02 |
| REINSTATEMENT | 2006-02-03 |
| ANNUAL REPORT | 2004-09-15 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
