Basic Information
| Provider Information | |||||||||
| NPI: | 1003935693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEASTERN ANESTHESIA OF NEW JERSEY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 N BEDFORD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105492553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
| FaxNumber: | 9146666777 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 FRANKLIN TPKE | ||||||||
| Address2: | SURGICARE SURGICAL ASSOCIATES OF MAHWAH, LLC | ||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074303516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
| FaxNumber: | 9146666777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 02/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | COHN | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9146668866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0129453 | 05 | NJ | MEDICAID |