Basic Information
| Provider Information | |||||||||
| NPI: | 1487029815 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW YORK ANESTHESIOLOGY MEDICAL SPECIALTIES, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW YORK SPINE AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 510 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132140510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152513105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6430 TRANSIT RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140431033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155526700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2015 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | TISO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3152513105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 03423585 | 05 | NY | MEDICAID |