Provider Demographics
NPI:1821376005
Name:OMNICARE MULTI SPECIALTY CENTER, LLC
Entity Type:Organization
Organization Name:OMNICARE MULTI SPECIALTY CENTER, LLC
Other - Org Name:OMNICARE ANESTHESIA, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:PARALEGAL
Authorized Official - Phone:718-774-0171
Mailing Address - Street 1:763-765 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4203
Mailing Address - Country:US
Mailing Address - Phone:718-774-0171
Mailing Address - Fax:718-773-7470
Practice Address - Street 1:763-765 NOSTRAND AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216
Practice Address - Country:US
Practice Address - Phone:718-774-0171
Practice Address - Fax:718-773-7470
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKLYN ANESTHESIA GROUP, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-22
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177953172V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty