Basic Information
| Provider Information | |||||||||
| NPI: | 1952450090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINLINE ANESTHESIA, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
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| City: | MASSAPEQUA PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117620270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312642035 | ||||||||
| FaxNumber: | 6312641418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 E 68TH ST | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100214903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125706945 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | AZNAVOORIAN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9177342288 | ||||||||
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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 | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.