Provider Demographics
NPI:1508818014
Name:JEFFERSON ANESTHESIOLOGIST SERVICES PC
Entity Type:Organization
Organization Name:JEFFERSON ANESTHESIOLOGIST SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-785-8509
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0091
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:830 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4066
Practice Address - Country:US
Practice Address - Phone:315-785-4313
Practice Address - Fax:315-779-5114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01140587Medicaid
NY01140587Medicaid