Basic Information
| Provider Information | |||||||||
| NPI: | 1114965035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORWICH ANESTHESIA ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 E RIVER DR | ||||||||
| Address2: | 5TH FLOOR , ATTN CREDENTIALING | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824022 | ||||||||
| FaxNumber: | 8602820834 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 WASHINGTON ST | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608236395 | ||||||||
| FaxNumber: | 8608236563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | D'AMATO | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8608236395 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 004199327 | 01 | CT | MEDICAID APRN GROUP # | OTHER | 004054763 | 05 | CT | MEDICAID |