Basic Information
| Provider Information | |||||||||
| NPI: | 1861498198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTRO ANESTHESIA SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117620270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312642030 | ||||||||
| FaxNumber: | 6312641418 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 NEW HYDE PARK RD | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166784725 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | KOPPEL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5166784725 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 12/20/2019 | ||||||||
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 | 02523926 | 05 | NY | MEDICAID |