Basic Information
| Provider Information | |||||||||
| NPI: | 1760704613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILKES-BARRE ANESTHESIA SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 COMMERCE DR | ||||||||
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| City: | NEW ROCHELLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 108015214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146373510 | ||||||||
| FaxNumber: | 9146333287 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 N RIVER ST | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187640001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708298111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2010 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9146373511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | PA | MEDICAID |