Basic Information
| Provider Information | |||||||||
| NPI: | 1871548636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY ANESTHES ASSOC., LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29140 | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100879140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007201664 | ||||||||
| FaxNumber: | 2077532020 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E MAIN ST | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117068408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319683163 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | MERRIHEW | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6319683163 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 01856835 | 05 | NY | MEDICAID | CN2724 | 01 | RAILROAD MEDICARE | OTHER |