Provider Demographics
NPI:1205880390
Name:PENN MAR ANESTHESIA, LLC
Entity type:Organization
Organization Name:PENN MAR ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-685-3555
Mailing Address - Street 1:PO BOX 931
Mailing Address - Street 2:
Mailing Address - City:HARPERS FERRY
Mailing Address - State:WV
Mailing Address - Zip Code:25425-0931
Mailing Address - Country:US
Mailing Address - Phone:410-819-0710
Mailing Address - Fax:410-819-0712
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 228
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-733-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060826L207L00000X
MDD0037485207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420POtherMARYLAND MEDICARE GROUP
MDDF7236OtherRR MEDICARE
MD412508800Medicaid
MDDF7236OtherRR MEDICARE