Basic Information
Provider Information | |||||||||
NPI: | 1073841698 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HAZLETON ANESTHESIA SERVICES, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 450 MAMARONECK AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | HARRISON | ||||||||
State: | NY | ||||||||
PostalCode: | 105282436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146372075 | ||||||||
FaxNumber: | 9146333287 | ||||||||
Practice Location | |||||||||
Address1: | 700 E BROAD ST | ||||||||
Address2: |   | ||||||||
City: | HAZLETON | ||||||||
State: | PA | ||||||||
PostalCode: | 182016835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705014000 | ||||||||
FaxNumber: | 5705016203 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2009 | ||||||||
LastUpdateDate: | 04/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOCH | ||||||||
AuthorizedOfficialFirstName: | MARC | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 9146373511 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
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 | 1023973930001 | 05 | PA |   | MEDICAID |