Provider Demographics
NPI:1417401266
Name:NORTH SHORE - LIJ ANESTHESIOLOGY, PC
Entity Type:Organization
Organization Name:NORTH SHORE - LIJ ANESTHESIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP & CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6058
Mailing Address - Street 1:PO BOX 417998
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7998
Mailing Address - Country:US
Mailing Address - Phone:914-666-8866
Mailing Address - Fax:914-666-6777
Practice Address - Street 1:480 BEDFORD RD BLDG B
Practice Address - Street 2:
Practice Address - City:CHAPPAQUA
Practice Address - State:NY
Practice Address - Zip Code:10514-1715
Practice Address - Country:US
Practice Address - Phone:914-666-8866
Practice Address - Fax:914-666-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100160302OtherGROUP MEDICARE PTAN
NY4690557Medicaid