Provider Demographics
NPI:1225229743
Name:OMNICARE ANESTHESIA
Entity Type:Organization
Organization Name:OMNICARE ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVANS
Authorized Official - Middle Name:
Authorized Official - Last Name:CREVECOEUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-986-0593
Mailing Address - Street 1:PO BOX 30036
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-0036
Mailing Address - Country:US
Mailing Address - Phone:718-369-3080
Mailing Address - Fax:718-369-3271
Practice Address - Street 1:55 GREENE AVE
Practice Address - Street 2:STE: LLA
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-1026
Practice Address - Country:US
Practice Address - Phone:718-622-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWLM751Medicare PIN