Basic Information
| Provider Information | |||||||||
| NPI: | 1104866698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEER PARK ANESTHESIA GROUP, LLP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 CATHARINE ST | ||||||||
| Address2: | P.O. BOX 550 | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668852318 | ||||||||
| FaxNumber: | 8457902675 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E MAIN ST | ||||||||
| Address2: | BON SECOURS COMMUNITY HOSPITAL | ||||||||
| City: | PORT JERVIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127712253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458587000 | ||||||||
| FaxNumber: | 8457902675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | OMAR | ||||||||
| AuthorizedOfficialFirstName: | HUSSEIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8668852318 | ||||||||
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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 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02728861 | 05 | NY | MEDICAID |