Basic Information
| Provider Information | |||||||||
| NPI: | 1124248018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SHORE ANESTHESIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 48 ROUTE 25A | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SMITHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117871431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318623540 | ||||||||
| FaxNumber: | 6318623604 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 ROUTE 25A | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SMITHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117871431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318623540 | ||||||||
| FaxNumber: | 6318623604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOERNER | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6318623413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.