Basic Information
| Provider Information | |||||||||
| NPI: | 1417401266 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE - LIJ ANESTHESIOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417998 | ||||||||
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| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022417998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
| FaxNumber: | 9146666777 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 BEDFORD RD BLDG B | ||||||||
| Address2: | |||||||||
| City: | CHAPPAQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105141715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
| FaxNumber: | 9146666777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
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 | A100160302 | 01 | NY | GROUP MEDICARE PTAN | OTHER | 4690557 | 05 | NY | MEDICAID |