Provider Demographics
NPI:1083614440
Name:SOUTHCOAST CARDIAC ANESTHESIA
Entity Type:Organization
Organization Name:SOUTHCOAST CARDIAC ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:THIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-679-7558
Mailing Address - Street 1:363 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-3703
Mailing Address - Country:US
Mailing Address - Phone:508-679-7558
Mailing Address - Fax:508-679-7147
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-679-7558
Practice Address - Fax:508-679-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9711741Medicaid
MAM21257Medicare ID - Type Unspecified
MA9711741Medicaid