Provider Demographics
NPI:1356625404
Name:NORTHEAST ANESTHESIA GROUP, LLC
Entity type:Organization
Organization Name:NORTHEAST ANESTHESIA GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BUSSANICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-313-4650
Mailing Address - Street 1:PO BOX 79
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-313-4650
Mailing Address - Fax:
Practice Address - Street 1:9226 KENNEDY BLVD
Practice Address - Street 2:UNIT A
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5312
Practice Address - Country:US
Practice Address - Phone:201-339-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06277300207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty