Basic Information
| Provider Information | |||||||||
| NPI: | 1689628786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIOLOGY ASSOCIATES OF BENNINGTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 252 | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042430252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007201664 | ||||||||
| FaxNumber: | 2077532020 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DRIVE | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | BENNINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 052015004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024475590 | ||||||||
| FaxNumber: | 8024406099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | TARAZI | ||||||||
| AuthorizedOfficialFirstName: | E. MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8024475590 | ||||||||
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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 | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0005739 | 05 | VT | MEDICAID | CD9169 | 01 | RAILROAD MEDICARE | OTHER |