Basic Information
| Provider Information | |||||||||
| NPI: | 1508812892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAMAICA ANESTHESIOLOGIST, PC | ||||||||
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| OtherOrganizationName: | JAMAICA ANESTHESIA ASSOCIATES, PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313917700 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 VAN WYCK EXPY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182066088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | MORISCO | ||||||||
| AuthorizedOfficialFirstName: | ANTOINETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7182066088 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LA0401X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207LC0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00977871 | 05 | NY | MEDICAID |