Provider Demographics
NPI:1962452516
Name:NARRAGANSETT BAY ANESTHESIA, LLC
Entity Type:Organization
Organization Name:NARRAGANSETT BAY ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCIVOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-407-7713
Mailing Address - Street 1:PO BOX 3072
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-3072
Mailing Address - Country:US
Mailing Address - Phone:781-407-7713
Mailing Address - Fax:781-407-0998
Practice Address - Street 1:440 SWANSEA MALL DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4114
Practice Address - Country:US
Practice Address - Phone:508-324-1171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9738461Medicaid
MA9738461Medicaid