Basic Information
Provider Information | |||||||||
NPI: | 1417997289 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ITENBERG | ||||||||
FirstName: | ALEXANDER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3308 | ||||||||
Address2: | TROY ANESTHESIOLOGISTS, PC. | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142403308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8668688419 | ||||||||
FaxNumber: | 8457902675 | ||||||||
Practice Location | |||||||||
Address1: | 2215 BURDETT AVE | ||||||||
Address2: | SAMARITAN HOSPITAL | ||||||||
City: | TROY | ||||||||
State: | NY | ||||||||
PostalCode: | 121802466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182713258 | ||||||||
FaxNumber: | 5182713101 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 02/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 159389-1 | NY | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 00843834 | 05 | NY |   | MEDICAID |