Basic Information
| Provider Information | |||||||||
| NPI: | 1881636397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED ANESTHESIA ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 TRAP FALLS ROAD | ||||||||
| Address2: | SUITE 414 | ||||||||
| City: | SHELTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064847623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039297353 | ||||||||
| FaxNumber: | 2039290756 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 TRAP FALLS ROAD | ||||||||
| Address2: | SUITE 414 | ||||||||
| City: | SHELTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064847623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039297353 | ||||||||
| FaxNumber: | 2039290756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | BLADEK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN OF ANESTHESIA TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2039297353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 004081725 | 05 | CT | MEDICAID |