Basic Information
| Provider Information | |||||||||
| NPI: | 1629272141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPSTATE ANESTHESIA SERVICES, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LONG ISLAND ANESTHESIA ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 MAMARONECK AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105282400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146373510 | ||||||||
| FaxNumber: | 9143656307 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 HEMPSTEAD TPKE DEPT OF | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115541859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726703 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9146373511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02890242 | 05 | NY | MEDICAID |