Provider Demographics
NPI:1942459672
Name:PROVIDENCE PARK ANESTHESIA ASSOCIATES, PC
Entity Type:Organization
Organization Name:PROVIDENCE PARK ANESTHESIA ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-853-8989
Mailing Address - Street 1:19855 OUTER DR STE L4E
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2027
Mailing Address - Country:US
Mailing Address - Phone:313-541-6420
Mailing Address - Fax:
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-465-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty